Out of Control

Foremost is that the matter of health records, let alone the concept of health IT, means different things to different people. For example, to a hospital, a “health information system” encompasses admissions, insurance records, treatment records, billing records and much more. Integrating these, at a local level, is an IT management headache in and of itself.

Then there are “medical records,” which is something of a misnomer because they have little to do with actual patient treatment. But since they record patient diagnostics and courses of treatment, they are crucial to billing and insurance claims. It’s these types of documents that pass back and forth from physicians to insurance companies. These records can be a nightmare of paperwork by themselves, as different insurance companies may demand the same billing data be formatted and presented in different ways.

Then there are “clinical records,” the actual case history of a patient. Integration, unification and portability of theses records is considered the Holy Grail of health IT. Its greatest benefit is also its greatest drawback: it would centralize every detail about an individual’s health history in one place – be it on a wallet-sized card or on a distant server housed with millions of other such records. Wherever it is, the vision calls for it to be network-enabled and the government must take some hand in it. Beyond that, the vision turns murky. Ask who will own the information, how it will be networked, who will have access and on what terms, and you get dozens of answers, accompanied by justifications and rationalizations.

And it’s here, on the networking aspect, where ALEC’s principles, and much of the debate, fall short. What’s needed is something to the effect of: “These ease with which electronic information can be replicated and shared requires necessary policies to assure the protection and privacy of consumer data.”

The trouble is, a statement like this may be antithetical to the whole notion of an interoperable health IT network, especially for clinical records. Wiser minds than I have put it, “you can have an open method of sharing information or you can have a high threshold of privacy, but you can’t have both.”

Much is made of the supposition that a health care IT network would lower costs, improve the quality of care and, overall, make the U.S. health care system more efficient.

Efficient for whom? What do we get from a standardized national network for the wider ability to exchange of medical data on consumers?

1) Portability of records. This is the motivation for consumers. I change doctors, the new physician can gain immediate and accurate information to my medical history, maybe from a magnetic strip on the back of a plastic card. In emergency situations, this can be a life-saver. Electronic records, because they can be housed in controlled environments, can also survive fire and storms. No one knows how many records were lost due to flooding from Hurricane Katrina. But electronic records are also susceptible to theft, and when millions are stored in one place, the target is especially tempting.

2) Lower transactional costs. Here’s the motivation for the supply side. Some estimates say administration adds $9 billion a year to costs. Health IT would let insurers and providers exchange information easier. Payments would be quicker. Cash flow would be better. Costs, at least in theory, would come down. But the case for consumer buy-in lies in the assumption that cost savings would be passed along. This is a reasonable assumption in any other market governed by supply-and-demand, but the current health care market is devoid of such mechanisms. The key problem, in fact, in health care is that most consumers are divorced from the costs of their treatment. And no one really knows the true cost of health care, Most providers base their billings on the way Medicare reimburses. Health IT might lower costs for insurers and providers, but I doubt by itself will it have any net effect on the cost or quality of health care that consumers receive. Like portability of records, it demands a lot of faith from consumers in the integrity of the system but nothing much in the way of concrete benefit.

3) A huge government database on the health of its citizens. The one plausible reason for the government to be involved in the Health IT process is that it is an insurer—it administers Medicare and Medicaid. It has the right to approach the market as any other big supplier, but at the same time, the risk is its very size, coupled with its inherent political power, can distort market mechanisms (a problem not limited to health IT). What I fear is that the federal government, with an all-too-close partnership with the insurance industry, will become both an administrator and central collector of personal health records on its citizens. Given the range of current health care policy proposals before the country—especially universal access—there’s no reason why this can’t happen.

Frankly, I question whether the government at any level should be promoting or sponsoring health care IT initiatives. To begin with, so much IT interoperability needs to be ironed out within and among the provider and insurer segments before we can coherently address the collection, storage and transmission of highly personal clinical health records.

The marketplace is still the best way to work this out, because, over the course of several stages, it will allow consumers, providers and insurers to come together in the best way, voluntarily agreeing on what and with whom personal data should be shared. While the health care industry is going slow on networking standards, I am no longer convinced that this is a bad thing. And I think we should begin to respect the market’s slower movement as a reflection of genuine concern about privacy and accessibility. I am leery of government efforts to force things along, especially when the very stakeholders are having trouble identifying how they expect the final process to work and who its biggest beneficiaries will be.