Medicare, Hospitals, Serious Harm and Death

The Inspector General of the Department of Health and Human Services, Daniel R. Levinson, published an Op-ed in USA Today that is well worth considering.  The column, entitled “Medical mistakes plague Medicare patients,” speaks volumes. Levinson writes:

Today’s hospitals are modern-day marvels of healing, and we expect them to be models of patient safety as well. But a just-released report from my office shows that medical care is falling short for too many hospitalized Medicare patients. A decade after an Institute of Medicine study placed preventable medical errors among the leading causes of death in the United States, our latest study found that a disturbing number of hospitalized patients still endure harmful consequences from medical care, 44% of them preventable. These instances, which the report calls “adverse events,” include infections, surgical complications and medication errors

Such occurrences are not always preventable, particularly since many Medicare patients are elderly and have complicated health problems. But enough patient harm is avoidable to make a strong case for action. Hospitals must improve, but they need the help of lawmakers, medical professionals and patients to do so.

We’ve written about this issue before here on HRW (in the context of various calls for medical malpractice reform as part of health care reform and studies that show hospital staff neither washing their hands regularly nor utilizing the simple but effective surgical checklist). The Institute of Medicine study Inspector General Levinson referred to estimated 98,000 deaths per year. Last year I wrote:

Bloomberg reports that “The U.S. Institute of Medicine found a decade ago that medical errors kill 98,000 Americans a year” according to Les Weisbrod, president of the Washington-based trial lawyers’ group, the American Association of Justice.

According to Medical News Today, the medical error fatality figures above were supported by “Dr. Chunliu Zhan and Dr. Marlene R. Miller in a research study published in the Journal of the American Medical Association (JAMA) in October of 2003. The Zhan and Miller study supported the Institute of Medicine’s (IOM) 1999 report conclusion, which found that medical errors caused up to 98,000 deaths annually and should be considered a national epidemic.

A study by HealthGrades found more than twice that number in “potentially preventable deaths.”

And now this study. Look at the numbers; they aren’t pretty–and they cast some present doubt on the 98,000 number if one considers the rubric, “contributed to their deaths.” Levinson writes:

Errors prolonged hospital stays

This study began in response to a congressional mandate to determine the number of harmful medical events Medicare patients experienced, and the cost to taxpayers. My office arranged for physician reviewers to examine a random sample of 780 Medicare patients discharged from hospitals around the country during the month of October 2008.

Physicians determined that about one in seven patients (13.5%) experienced at least one serious instance of harm from medical care that prolonged their hospital stay, caused permanent harm, required life-sustaining intervention, or contributed to their deaths. Projected to the entire Medicare population, this rate means an estimated 134,000 hospitalized Medicare beneficiaries experienced harm from medical care in one month, with the event contributing to death for 1.5%, or approximately 15,000 patients.

That’s per month. Some quick math will give us the yearly death figure: 15,000 x 12 months = 180,000 per year. And that’s just Medicare patients.

The “seriously harmed” equals 1,608,000 per year. Again, just Medicare.

Levinson continues:

Strikingly, medication errors factored in more than half the patient fatalities in our sample, including use of the wrong drug, giving the wrong dosage, or inadequately treating known side effects. Such events were commonly caused by hospital staff diagnosing patients incorrectly or failing to closely monitor their conditions.

Less serious harm also occurred. An additional one in seven hospitalized Medicare patients experienced temporary problems, such as allergic reactions or injuries from falls. And many experienced multiple events, including an elderly heart patient who had six separate events during a single hospital stay. Obviously, this situation is unacceptable — and expensive, costing taxpayers more than $4 billion a year due to the need for additional treatment or longer hospitalizations (and even more if you add costs for follow-up care).

I’ve said it before and I’ll say it again. “Seemingly, one would define “defensive medicine” as that which a doctor [or hospital] does, which he or she would not do, if solely exercising his or her [or its] discretion without the fear of being sued. Therefore, might I suggest that “defensive medicine” is only excessive if the doctor’s [or hospital's] best estimation of the situation is correct.”

You can read the rest of Inspector General Levinson’s Op-ed here. He offers some direction– much needed direction.

Reform Rodeo! The Summit, Speed Dating, and More.

1. Summit!: Fretting about how to get your dose of tomorrow’s “summit”? Don’t worry, CSPAN has got you covered for the Health Care Summit that is kicking off at 10am.

2. Managed Care Meltdown?: Joe Paduda at Managed Care Matters points out that the Anthem rate increases have shown an inability for private insurers to control costs.  What Paduda is missing in his piece is advice to private health insurers about how to manage costs without another “managed care backlash” like we had in the 1990s.

3. The Cost Conundrum’s Conundrum, or Just a Canard?: Maggie Mahar has a beef with the New York Times’ channeling of Dr. Bach’s New England Journal of Medicine article, where Dr. Bach criticized the  Dartmouth Atlas researchers’ methodology by claiming that they failed to risk adjust. Dr. Atul Gawande also believes the criticism is misplaced.

4. Health Care and Reconciliation are BFFs: NPR reports on a somewhat cozy relationship between reconciliation and previous health care initiatives.

5. What do speed dating and OB/GYN docs have in common? Kevin MD discusses how hospitals are utilizing speed dating techniques to match obstetricians with potential patients.

6. HIT, Yeah You Know Me: Dr. John Halamka with a slew of handouts from the HIT Policy Committee’s recent meeting, as well as notes from a recent meeting of the HIT Standards Commitee.

Google Buzz & Your Digital Health Doppelganger

At this point, it is fair to say that everyone has either heard or read about how Google’s latest foray into social networking, Google Buzz, has gotten off to a bumpy start due to privacy concerns. We can only speculate as to why Google failed to appreciate Buzz’s underwhelming privacy protections. Maybe Google was aware of the privacy issues but felt that they were outweighed by the “turn key” social network that would automatically be created by leveraging the user’s own Gmail contact list. Alternatively, Google may have simply not appreciated the privacy issues. Whether Buzz’s threats to privacy justified the immense firestorm that has occurred is besides the point. Regardless of whether the privacy issues are justified or not, as consumers utilize social networking tools to a greater degree, they are becoming more aware of the potential privacy problems, and are becoming more vocal when they disapprove.

One of the more troubling aspects of Google Buzz was that  it automatically created a network of users in your Buzz social network based on the addresses you emailed most in Gmail. Buzz would then automatically start following those contacts. The issue was compounded by the fact that Google made the list of people you were following on Buzz public by default. This automatic follow-and-tell-the-world approach that piggybacked off of Gmail users’ contact list has since been tweaked. Currently, a user joining Buzz is offered suggestions of who to follow, and those whom they choose to follow are not broadcast for the world to see.

A hypothetical within the health care setting may serve to illustrate why this approach was problematic, and will also illustrate why social networking may have profound implications for our “digital health doppelganger.” Under the initial iteration of Buzz, physicians using Buzz who were following the Buzz feeds of their patients would, simply by using the service, make the names of who they were following public to all their other followers.  In other words, a patient could see the names of all the individuals that their physician was following, including any who happen to be patients.  This situation could be disastrous both personally and economically if the individual was being treated by a physician specializing in schizophrenia or HIV/AIDS–diseases that have, for whatever reason, become highly stigmatized and prone to various discriminatory responses. It is therefore clear that myriad privacy and confidentiality issues arise, including questions of whether such information would be considered protected health information under HIPAA. That the disclosure of fiduciary relationships is troublesome is nothing unique to health care: in the legal profession, the mere existence of an  attorney-client relationship can be considered privileged information.

But back to Health IT, an area where  our digital health doppelganger is progressing through its adolescence in a landscape of social networks, electronic health records, and a highly fragmented health care delivery system. A number of general areas of concern arise. Including:

1) the online storage of our personal sensitive health information (e.g. in EHR and PHR databases, and Law Enforcement and “Fusion Centers”).

2) current modes of interfacing with our online health data (e.g. access viz. home computer, mobile phone, kiosks).

3) future modes of interfacing with our online health data (e.g. increasing mobile use, RFID, Smartcards, video playback of encounters).

4) how others will access and use our online health data (e.g. Primary care physician accessing our PHR, Site-wide access by Accountable Care Organizations, targeted advertising in PHRs based on the content found within the PHR service or services it can connect to).

5) how we will interact with the health data of others (e.g. PatientsLikeMe.com, increasing meta-analysis of health data available through future nationwide interoperable EHR systems).

6) how our increasingly digitized health care persona will exist alongside our professional and social personas.

Google and  Microsoft offer immensely useful services, but which concomitantly force us to more deeply analyze these issues, particularly the last issue, which both feeds back, and is affected by, each of the other issues. More than any other company, Google has sought to integrate their products to make communication and organization as seamless as possible. For example, The to-do list in Google Tasks is, not surprisingly, symbiotic with Google Calendar, while the latter service interfaces with Gmail by scanning the content of a user’s email for the tell tale signs of future events, and and offering to add a calendar entry.  For those of you not using Google, the right portion of the picture below illustrates how Google recognizes the contents of the email message, and asks the Gmail user if she wants to add the event to their Google Calendar.

The simple example above makes it easy to imagine similar features being offered in PHRs like Google Health and Microsoft HealthVault–PHRs that are provided by entities that either offer social networking tools alongside their PHRs, or who plan to somehow utilize outside data that is available through other means.  As consumers, we must determine how precocious we want our online health persona to be. It must be noted that there is nothing intrinsically wrong with this integration, and such integration certainly offers many benefits to providing better information to patients and physicians.

However, both Google and Microsoft are unique in that they are introducing personal health records to their users who have already ceded to them an extraordinary amount of highly personal information.  This raises interesting questions that will test our willingness to integrate our social network with our health identity. For example, how should Google Wave–Google’s new hybrid email/chat service–be interfaced with Google Health? Furthermore, what status will a physician-patient conversation thread on Google Wave or Google Buzz be provided? Is it more like a health record or a phone conversation? Would it be acceptable for Google Health to utilize health related information that it recognizes within your Gmail messages? Even though Google has refrained from displaying targeted ads within Google Health, would the reverse be acceptable, whereby Gmail advertisements are determined based on Google Health data?  Would it be inappropriate for Google Health to utilize information about your newly diagnosed diseases  to connect you to health-related social networks such PatientsLikeMe?

Users are likely to forget about Google Buzz’s initial oversights, especially in the short-attention span sphere that is the Internet. This is okay, so long as changes are made to appropriately address such glaring issues. We must, however, ensure that we tackle the much more difficult question of what limits to place on the subtle, yet no less powerful, forces that are altering the breadth of our increasingly digitized and integrated online persona.  For many of us, the personality of our digital health doppelganger is taking shape on our screens and our smartphones. Are we going to like what we see? And perhaps more importantly, will others?

Micro-Chipping (and then pulling the plug on) Grandma as part of HIT and the Public Option

I had the opportunity to speak with one of our Health Law professors from private practice the other day (some professors teach full time, others teach only part time in addition to working full time as attorneys or judges), and he had been practicing (and teaching) health law for decades. He was both amazed and incensed: at our inability as a country to have a reasonable discussion about health care; that a provision to remunerate consultations regarding end of life issues somehow turned into “pulling the plug on grandma” and “death panel” sound bites–from people who should (or do) know better; and that people somehow believe that “rationing” doesn’t exist right now in the for profit health insurance system. “They speak as though their insurance policies are unlimited. They are not. There are insurers denying coverage all the time.”

This article in the New York Times’ Prescriptions won’t make him feel any better. It regards a recent chain email which tells of the impending forced implantation of microchips into patients as part of a government sponsored health plan.

Prescriptions reports:

…fears of death-panel bureaucrats voting to euthanize elderly Americans may pale in comparison to the latest fright point: according to a widely forwarded chain e-mail, the Democrats’ health care bill would require anybody who enrolls in a new government-run health insurance plan “to have a data-receiving microchip implanted in their bodies.”

The assertion would seem to tie together policy points from both the House-passed health care measure, which would create a government insurance plan, or public option, and the economic stimulus measure earlier this year, which approved billions of dollars for health information technology.

The widely distributed email is said to have prompted House Speaker Nancy Pelosi to issue a Myth Buster fact sheet:

Myth: People who enroll in the public health insurance option will be forced under the law to have a microchip implant.

Fact: The Affordable Health Care for America Act does not have any provision requiring any person to have a microchip — or anything else –implanted on their bodies for any reason.

The Times also notes that “Ms. Pelsoi’s office also noted that “PolitiFact — the Pulitzer-prize winning Web site — labeled this claim a ‘Pants on Fire’ lie, its highest degree of untruth.”

Reform Rodeo

Some highlights from around the health care blogosphere and elsewhere:

1. Is there a Deal to be Made on Health Care? An Interview With Sen. Lindsey Graham (Ezra Klein) — Klein provides an interesting interview with Senator Graham where the conservative Senator appears to stand for reasoned debate and dialogue regarding reform initiatives, but begging the question as to whether Graham will follow through on his promise of reaching across the aisle.

2. Op-Ed: A Practicing Doctor’s Prescription for Health Care Reform — The Health Care Blog ran an interesting op-ed by physician Jordan Shlain, who discusses the role of personal responsibility in reforming our health care system.

3. Health care debate turns vile with Nazi analogy — University of Pennsylvania Bioethicist Arthur Caplan provides a unique insight into the dangers associated with the recent vitriol surrounding the health reform debate.

4. Google’s First Quarter Lobbying Report - As noted in a recent HRW post, Google is playing a significant role in the drive for personal health records. While not necessarily a demonstration of Google’s fight against the regulation of vendors like Google Health, the sixth page of the report does indicate that the company has spent big bucks lobbying Congress on–you guessed it–personal health records.

5. In case you missed it — HRW’s own Seton Hall Law Associate Dean and Professor of Law, Kathleen M. Boozang in The Health Care Blog: “AHLA on the Stark Law and its Revision: a Good Step Towards Holistic & Ethical Reform.” (Originally posted here on HRW, then picked up by THCB).

HRW Wild card pick:

6. Hans Rosling shows the best stats you’ve ever seen — For those of you a little weary of the current health reform debate in the U.S., and who haven’t yet seen Rosling’s jaw-dropping 2006 presentation, it is definitely worth a look. TED has many other fantastic videos on topics that can certainly provide insights that might well be applicable to the U.S. health care debate.

Electronic Medical Records: It’s Not too Late to Build the Tower on an Interoperable Platform

Both the NY Times and the Boston Globe’s Health Blog, White Coat Notes , have recently run interesting articles on Electronic Medical Records (EMR). Both are based on articles published this last week in the New England Journal of Medicine. We’ve recently posted on the subject of EMR, and if you’d like some background information (as well as an introduction and a link to the pivotal work of Professors Sharona Hoffman and Andy Podgurski) you can find it here: Electronic Medical Records: How to Prevent the Creation of a Costly High-Tech Tower of Babel.

The first NEJM article, Use of Electronic Health Records in U.S. Hospitals, Ashish K. Jha, M.D., M.P.H., et al., was financed by the federal government and the Robert Wood Johnson Foundation and was based on a survey of nearly 3000 hospitals. The report, described by the Times as “the most definitive measure to date of the use of computerized patient records by hospitals,” shows that

…only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems.

A further breakdown of the components which constitute “comprehensive” and “basic” can be seen here.

Prior to this study, the numbers, based on what Steve Lohr of the NY Times described as “less rigorous studies,” were thought to be higher. The authors of Use of Electronic Health Records in U.S. Hospitals conclude that

The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.

Perhaps the good news here is that the relative scarcity of EMR implementation thus far means that we can yet still devise an interoperable system without rendering substantial but incompatible investments obsolete. Which is to say that we are not yet too far down nine different non-intersecting roads and that “a communicative Tower” can still be built, and sustained, on a Platform.

No Small Change for the Health Information Economy

Interoperability brings us to Elizabeth Cooney’s thoughtful and succinct post in the Boston Globe regarding the other NEJM article,  No Small Change for the Health Information Economy, Kenneth D. Mandl, M.D., M.P.H., and Isaac S. Kohane, M.D., Ph.D.

As do Professors Sharona Hoffman and Andy Podgurski, the authors of “No Small Change…” stress the need for flexibility, interoperability, liquidity of information, and the ability to substitute technologies as the need arises.  To do this they propose governmental encouragement of the use of a platform with interoperable applications (blog builders, think: “plug ins” and “widgets”)  In a recent post we noted that

In the words of Dr. Farzad Mostashari,  an assistant commissioner in New York City’s health department and head of the much heralded Primary Care Information Project (which is functioning as a sort of I.T. Department for many of the City’s doctors using EMR),  “There’s no way small practices can effectively implement electronic health records on their own. This is not the iPhone.”

Mandl and Kohane suggest that it should be. They make apt comparisons to the iPhone and ATM machines. Elizabeth Cooney’s article, “Health IT can learn from the iPhone and ATMs,”  explains the comparisons quite well and is well worth the minute it will take to read– and if you have another three minutes, I highly recommend you take a quick look at Mandl and Kohanes’ brief but important article. There’s a link to it here, and there’s one in Elizabeth Cooney’s article also.

Dr. David Blumenthal: National Health Care Information Technology Coordinator

President Obama has appointed Dr. David Blumenthal as the National Health Care Information Technology Coordinator. Dr. Blumenthal is a former Harvard Medical School Professor who, as reported by Kaiser.org, “has conducted a number of studies related to health care IT” and has “served as director of the Institute for Health Policy at the Massachusetts General Hospital/Partners HealthCare System and as a senior adviser to President Obama during his campaign.”

As National Health Care IT Coordinator, Dr. Blumenthal can be expected to play a large role in the direction of how the 19 billion dollars apportioned for Health IT in the recently enacted stimulus package will be spent.

Dana Blankenhorn over at ZDNet Healthcare has written a short and interesting post on Dr. Blumenthal. Among other things worth noting in the post, Blankenthorn writes that Blumenthal has been quoted as “saying IT grants should go to inner-city and rural hospitals, as well as small practices, while most health IT money should go to incentives for improving the quality of care.”

As for the choice of Dr. Blumenthal, Blankenhorn writes

The good news is he’s a policy expert and not a vendor. The bad news is he’s a policy expert and not a technologist. He is a renowned health IT advocate who knows his way around bureaucracies but he is not a geek.

This means Blumenthal has not expressed a view on open source vs. proprietary software. He also hasn’t gotten his hands dirty in the health IT trenches.

Having said that, one might hope that Dr. Blumenthal is familiar with the work of  Professors Sharona Hoffman & Andy Podgurski.

Electronic Medical Records: How to Prevent the Creation of a Costly High-Tech Tower of Babel

Steve Lohr of The New York Times has written an article, “How to Make Electronic Medical Records a Reality” (a follow-up to “Health Care That Puts a Computer on the Team” 12/26/08) that it is well worth taking the few minutes requisite to read it.

Professors Sharona Hoffman & Andy Podgurski have published an article in the Harvard Journal of Law & Technology that should be on Obama’s nightstand. “Finding a Cure: The Case for Regulation and Oversight of Electronic Health Records” will take more than a few minutes to read, but for those charged with the responsibility of making the prospect of Electronic Medical Records a reality, it should be required reading–because, as the authors point out, we simply cannot afford to get this wrong:

The benefits of EHR systems will outweigh their risks only if these systems are developed and maintained with rigorous adherence to the best software engineering and medical informatics practices and if the various EHR systems can easily share information with each other. Regulatory intervention is needed to ensure that these goals are achieved. Once EHR systems are fully implemented, they become essential to proper patient care, and their failure is likely to endanger patient welfare.

The Journal article is essentially a map, designed to point out hazardous terrain and harness the resources at hand to effectuate a comprehensive Electronic Health Record system– and, through interoperability and regulated standards, to prevent the creation of a costly high-tech Tower of Babel. As the authors remind us, in this territory, malfunction and miscommunication can be deadly–and the concerns of the market are not necessarily coextensive with the common weal.

For those of us who have an interest in the subject, and are convinced that it is essential to have a comprehensive guide (if not a blueprint) for “how to get this right” — take heart–it’s here, and I highly recommend you take the time to read it–and then pass it on and up until it reaches that nightstand, if it’s not already there.

How to Make Electronic Medical Records a Reality

The NY Times article depicts the paucity of EMR use at present (17%) in terms of  ”market failure,” and points out that U.S. Government guidance and investment in growing (”jump-starting”) industry and technology is not novel. Lohr writes:

…computer technology and the industry really flowered in the United States. That happened in no small part because the federal government nurtured the market with heavy investment, mainly by the Defense Department, and by choosing standards, like the Cobol programming language.

Today, Washington is about to embark on another ambitious government-guided effort to jump-start a market — in electronic health records. The program provides a textbook look at the economic and engineering challenges of technology adoption.

Lohr correctly points to the chasm which exists in EMR usage between large practices and small, and the failure of the market to incentivize further usage by doctors in these smaller practices. Lohr states:

These larger groups have the scale to invest in information technology, and they are often insurers as well as providers, so they benefit directly from the cost savings. Yet these large groups are the exceptions in American health care. Three-fourths of the nation’s doctors practice in small offices, with 10 doctors or fewer. For most of them, an investment in digital health records looks like a cost for which they are not reimbursed.

It is that “market failure,” says Lohr that the Obama plan seeks to address. To that end, the legislation which has devoted $19 Billion towards this “jumpstart,” “calls for incentive payments of more than $40,000 spread over a few years for a physician who buys and uses electronic health records.”

The legislation also requires that this payment to doctors be in exchange for “meaningful use,” but thus far the term has been left undefined.

We addressed both of these concerns on this blog in mid-January in response to a post on Health Affairs by Dr. David Brailer, Chairman of Health Evolution Partners, a health care investment fund. Read more

Prolegomena to Prononymity: What’s the Worst that Can Happen?

America needs electronic medical records (EMR). There are plenty of reasons why we are so far behind other nations in consolidating medical data: lack of strong central leadership on the issue, unwarranted faith in markets to produce solutions, and overwhelmed medical professionals who have little if any slack time to put a new system into place. Even as President Obama pushes for investment in EMR, privacy concerns are also slowing down progress:

Lawmakers, caught in a crossfire of lobbying by the health care industry and consumer groups, have been unable to agree on privacy safeguards that would allow patients to control the use of their medical records. . . . The data in medical records has great potential commercial value. Several companies, for example, buy and sell huge amounts of data on the prescribing habits of doctors, and the information has proved invaluable to pharmaceutical sales representatives.

“Health I.T. without privacy is an excellent way for companies to establish a gold mine of information that can be used to increase profits, promote expensive drugs, cherry-pick patients who are cheaper to insure and market directly to consumers,” said Dr. Deborah C. Peel, coordinator of the Coalition for Patient Privacy, which includes the American Civil Liberties Union among its members.

Health IT turns out to be one many areas where a drive for prononymity–that is, the de-anonymizing of records of on- and off-line life–is running up against a wall of wary citizens and consumers. In the health field, I think that resistance is only going to end if we have a robust “backstop” of health care in place so that citizens don’t have to worry about losing all coverage if a digital dossier presents them as a bad risk. (Medicaid as presently constituted does not count.) Far from overwhelming the health care system with pent-up demand, universal health coverage may be a prerequisite for generating support for the type of EMR that will provide us all with far better care.

A trend to prononymity in general should be matched with greater commitment to assuring that it won’t result in particularly harsh results. For example, people should not be denied a job for being identifiable as a Democrat in a blog post, whatever Monica Goodling thinks. Nor should doctor’s notes about a patient’s dark thoughts come back to haunt the patient when she or he applies for medical insurance. And if they do, there should be a genuine insurer of last resort available–not the patchwork of Medicaid and charity care that presently leave so many uninsured people falling through the cracks.

That’s one reason why I advocate the development of a Fair Reputation Reporting Act, which would allow individuals to know the documentary basis of certain key adverse decisions. I summarize the proposal here:

Reputation regulation has become essential because traditional restrictions on data flows inadequately constrain decisionmakers and important intermediaries (including search engines and bulletin boards). . . . Persistent and searchable databases now feed unprecedented amounts of poorly vetted information into vital decisions about employment, credit, and insurance. Rumors about a person’s sexual orientation (or experiences), health status, incompetence, or nastiness can percolate in blogs and message boards.

Even if the First Amendment and anonymity protect the authors of such rumors, affected individuals deserve to know whether certain important decisionmakers rely on them. In limited cases, the intermediary source of the information should also provide the target of a derogatory posting with the opportunity to annotate it. A Fair Reputation Reporting Act would empower individuals to know the basis of adverse employment, credit, and insurance decisions-and to go to their source (and the source of their salience) to demand some relief from digital scarlet letters.

In summary, privacy concerns are only likely to die down if individuals know either 1) that the consequences of a privacy breach are not likely to be severe or 2) that they can find out instances of the improper use of data. In the health care context in the US, neither qualifier holds: the individual insurance market routinely denies care to individuals on the basis of pre-existing conditions, and individuals have little sense of exactly how such determinations are made. Prononymity needs to work both ways: if our health conditions are to be the subject of increasing availability, so too must the decision-making processes that could use that data to our detriment become more transparent.

PS: Market mavens may promote a “Google Health Search” as the optimal solution here. If this 800 pound gorilla can get all the publishers in line to settle their copyright claims, perhaps it has some chance at bringing the medical industry to heel; however, the political power of doctors and insurers dwarfs that of publishers. The concentration of that much data in one company should also provoke some worries.

Dr. David Brailer and Electronic Medical Records: Perhaps the Chairman Doth Protest Too Much

Dr. David J. Brailer, appointed by President Bush in 2004 as the first National Coordinator for Health Information Technology, has written an article for Health Affairs worth reading. Dr. Brailer notes that President-elect Obama “has pledged $50 billion to bring health information tools into widespread use (which is $49,950,000 more than President Bush gave me to spend).” (Note: as the present budget for the office of National Coordinator is a little more than $66 million, I believe Dr. Brailer meant to say that the budget during his tenure was roughly $50 million, which would make Obama’s $50 billion $49,950,000,000 more. Apparently, I’m not the only one confused by billions).

Having said that, Dr. Brailer has some suggestions worth noting, not the least of which is that ensuring structural compatibility and integration of data systems are paramount necessities which will require more than just “hiring the geek squad.” He states

Setting up an electronic health record is a complex task, requiring data integration, clinical algorithms and complex software customization. Likewise, helping physicians and other health care workers learn to work with electronic tools is more than point-and-click training. Electronic health records change the very nature of health care work - clinical decision-making, communications, documentation and learning. Our national transition to digital medicine requires a large supply of specialists - upwards of 50,000 people, including physicians, nurses and pharmacists - who understand both clinical medicine and information technology. It takes years to train these people, and they are already in short supply, so now is the time to start.

I have no contention with the assertion that “setting up an electronic health record is a complex task,” and surely, at the end of a $50 billion investment no one wants to look up to see a Med e-record Tower of Babel. But Dr. Brailer’s assertion that “helping physicians and other health care workers learn to work with electronic tools is more than point-and-click training” is somewhat at odds with recent articles in The NY Times, one of which shows what an electronic medical record looks like and explains how pertinent and potentially life saving information “is just a few clicks away.”

Dr. Brailer also states that we need to address what he characterizes as

…the growing chasm between the physicians and hospitals that have electronic records and those that do not. Most large and urban hospitals as well as larger physician practices are far along in using electronic health records. Rural hospitals, nursing homes and small physician practices lag far behind. They face many barriers, but foremost among them is the lack of capital to purchase and implement information tools.

Dr. Brailer states that “Sales pipelines and hospital and physician budgets show that electronic health record purchases have slowed, indicating that the market wave has gone as far as it can. Now is the time for government incentives to help along those who do not have these systems.”

But Brailer wants to incentivize the “use” of electronic medical records much in the way that Congress has done so regarding “electronic prescribing.” He states: “Medicare pays physicians a 2% bonus for using eprescribing on appropriate patients starting in 2009, and this incentive converts to a 3% penalty for those who do not eprescribe in 2013.”

Of course, Brailer is right to make the distinction between “purchase” and “use.” No one wants to subsidize a high tech, dust gathering coat rack. He makes the point that “We should not incent physicians and hospitals simply to purchase electronic records. We get no benefit when a physician or hospital buys an electronic record. What we should do is reward the use of these tools as part of a patient’s care.”

What he fails to address, however, in this incremental ROI “pay for use” approach is what he characterizes as the “foremost barrier” to those “Rural hospitals, nursing homes and small physician practices” on the other side of e-med record chasm: initial capital outlay.

Considering the financial difficulties of many hospitals-and the chilled credit markets- it is somewhat difficult to envision how the gradual return on investment through “pay for use” will offer great affect for those medical service providers who, at present, have a “lack of capital to purchase and implement information tools.” It is not, however, hard to envision how such a continuous “pay for use” incentive would benefit those larger providers who have already implemented electronic medical record systems.

Additional payments each time they used what they have already invested in would, no doubt, provide an additional dividend which these typically larger providers would greatly appreciate. It is not at all clear, however, that such a program, requiring significant investments of capital-which may well not be available at this time-will lessen the “chasm” by any great measure.

The New York Times has reported that

For most doctors, who work in small practices, an investment in electronic health records looks simply like a cost for which they will not be reimbursed. That is why policy experts say any government financial incentives to use electronic records - matching grants or other subsidies - should be focused on practices with 10 or fewer doctors, which still account for three-fourths of all doctors in this country. Only about 17 percent of the nation’s physicians are using computerized patient records, according to a government-sponsored survey published in The New England Journal Of Medicine.

The Times also reports that those who are presently using electronic medical records tend to be part of larger health care organizations.

No longer the National Coordinator for Health Information Technology, Dr. Brailer is now the Chairman of Health Evolution Partners; it is a health care investment fund:

“Health Evolution Partners invests in the world’s leading health care companies. We seek out companies that are driving critical shifts in how health care is financed, organized and delivered.”

….We use these assets to help our portfolio companies:

• Build strategies with unusually high potential
• Navigate and mitigate business, policy and regulatory risks
• Develop and shape the market for their products and services
• Enhance the growth and returns for their shareholders

Electronic Medical Records: What They Look Like, What They Can Do

The Obama administration has stated that the institution of electronic medical records will play a role in its forthcoming efforts to reform health care in the United States. According to the NY Times, “During the campaign, Mr. Obama vowed to spend $50 billion over five years to spur the adoption of electronic health records and said recently that a program to accelerate their use would be part of his stimulus package.” Max Baucus, Senate Finance Committee Chairman, has stated that the stimulus package will likely include grants and tax breaks for doctors and hospitals to invest in health IT. The Washington Post has reported that its sources “cited $10 billion as a potential figure for health IT in the stimulus package.” In addition, CMS has modified its Medicaid and Medicare reimbursement payments to include a 2% incentive to encourage hospitals to upgrade their records systems with health IT and a 2% penalty within two years for hospitals that do not adopt health IT.

The NY Times has run an article featuring the use, efficacy, and potential of electronic medical records. The article also features an example of what an electronic medical record looks like.

For a number of reasons, the article is well worth a read. Find it here.

First Steps; Web-based Medical Records?

The Wall Street Journal Health Blog reports that the Democrats are at work trying to include some aspects of health reform into the economic stimulus package slated to be unveiled next month.

The plan is said to include help for the Medicaid program. The WSJ Health Blog also stated that “according to the Washington Post, there’s also talk of packing the stimulus package with provisions to retrain medical workers, bolster the State Children’s Health Insurance Program and expand Cobra.”

Max Baucus, Senate Finance Committee Chairman, is said to have stated that the package will likely include grants and tax breaks for doctors and hospitals to invest in health IT. The Washington Post is said to have reported that it’s sources “cited $10 billion as a potential figure for health IT in the stimulus package.” Read full story here.

In a related story, the Health Blog reported that the cousin of President George Bush, athenahealth CEO Jonathan Bush, has called for the use of a Web-based platform for health IT initiatives. Athenahealth currently provides a Web-based medical records platform for 17,000 customers,” Bush says. Software ‘isn’t the dominant approach in financial services or retail banking or anywhere else, and it shouldn’t be in health care.’” Read more here.

Member of Obama’s Campaign Health Care Advisory Committee Cites Private Sector Increase in Computer-based Health Records Systems

Glen Tullman, CEO of Allscripts and a member of Obama’s campaign health care advisory committee, cited the need to cut costs and reduce the risk of medical errors as reasons for an increase in physician and hospitals switching to computer based health records. “According to Tullman, Allscripts, the largest U.S. provider of software to physicians, has seen a fivefold increase in the number of physicians who are using electronic prescribing technology.” Tullman also noted that CMS has modified its Medicaid and Medicare reimbursement payments to include a 2% incentive to encourage hospitals to upgrade their records systems with health IT and a 2% penalty within two years for hospitals that do not adopt health IT (Bloomberg, 12/9). Read more here.