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By the numbers, on single payer the Democrats are wussies

Jun 6, 2009• 33

By Matthew Holt

Now before I explain why I say the Democrats are girlie-men, let me say three quick things.

1. I am not a supporter of Medicare-for-all, or Canadian style, single-payer (or anything primarily based on fee-for-service payment) although they are both clearly superior to the American status quo. (I am in favor of real universal insurance, but that’s different and less limited than just single payer).

2. It’s still only 50–50 that we’ll get any reform this year, and what we will get will basically be an expansion of one of the worst-designed government programs—Medicaid—mixed with some very modest regulation of the worst behavior of the private insurance companies. And with the exemptions to the individual mandate and for small business at best we’ll get to around 95% coverage—and that’s not counting the undocumented immigrants, who are about another 3–5% of the population and who will still get care and thus still have to be paid for somehow. And the likely Kennedy/Baucus compromise plan has no sustainable insurance payment structure that I can see.

3. The data is a little murky and all sides kinda cheat with polling data (and bankruptcy data too).

But imagine for a moment that Dick Cheney & George W. Bush had 60 votes in the Senate, a disgraced opposition, and carte blanche to do what they liked because of a real national crisis (In other words a much better political situation than they faced in 2001 & 2003).

And imagine that there was a policy that their party’s supporters overwhelmingly favored. Do you think for a moment that they’d be looking for compromise even if what they were doing was egregiously and clearly wrong in both terms of public policy and fairness? For instance, cutting tax rates on dividends to less than half what poor suckers who work for a living have to pay, even though the benefits went largely to millionaires and billionaires. Or even worse eliminating estate taxes, when the benefits went only to millionaires and billionaires.

Actually we don’t have to imagine. We know what Cheney/Bush did. They passed the legislation they wanted, and damn the rest of us. And then did it with way less political clout than Obama has—Bush didn’t even win the election after all in the way most of us understand (err…by getting more votes than the other guy).

Now imagine that there’s a policy that polls show at least 35% and (depending who you believe) perhaps up to 60% of all Americans want, and that the same polls show that a vast majority of Democrats want it. And of course Obama’s political situation is way stronger than the Cheney Administration’s was.

In that situation and if they had a different political philosophy, wouldn’t the Cheney Administration just ram through single payer?

So by the numbers, in not even considering the single payer option (not even Kennedy’s plan comes close), the Democrats are proving themselves to be wussies.

CODA: I changed one letter in one word of this piece so that the humorless crowd in the comments didn’t detract from the real offensive stuff going on here–50 million un and under-insured with no political will to do anything serious about it. But if the comments don’t make sense, my original defense is in there too.

Are Today’s EMRs Up to the Job?

Jun 6, 2009• 23

By RICHARD SCOVILLE

RS Head Shot 1 This post is a bit different from most of the policy points, institutional cases and reports of technical innovations that I’ve been reading on THCB in the past months. I want to pose the above Question to the readers of this blog, since many of you are uniquely positioned help answer it in your comments. And I have a hope that your responses to this Question will help nuance the technical and policy debate over EMR adoption.

First, let’s unpack the Question:

1. THE JOB. In the past several years, a number of public and private initiatives, most recently ABMS’s Improving Performance in Practice (a project with which I am affiliated) and NCQA’s Patient Centered Medical Home, have been making fitful progress toward a new post-reform model of primary care: patient-centered, accessible, care-coordinating, population-focused, prepared, proactive, and the rest. These collaboratives and demonstration projects have all stressed the importance of computerized ‘registry functions’ as the foundation for these progressive capabilities. One, the Health Disparities Collaboratives run by HRSA, went so far as to commission a registry program and provide it free to participating clinics.Continue reading…

MedPac on Steroids

Jun 5, 2009• 15

By MAGGIE MAHAR

I’ve long argued that Medicare reform will pave the way for healthcare reform, and that the Medicare Payment Advisory Commission’s (MedPac’s) recommendations could serve as a brilliant blue print for overhauling Medicare. (Also see our Century Foundation report on Getting More Value From Medicare).

Now President Obama appears to be backing a proposal that would empower MedPac to realize its vision for reform. Earlier this week, in a White House meeting with Senate Democrats, the president reportedly “went out of his way” to mention a bill, introduced by Senator Jay Rockefeller ( D-W.Va) that would move decisions about Medicare benefits away from Congress, by turning MedPAC into an independent executive agency. Currently, MedPac is an independent panel that advises Congress. It has no formal power. But under Rockefeller’s bill it would be able to implement its recommendations and fund policy initiatives.

Wednesday afternoon, the White House announced that the President has gone a step further by releasing a letter from President Obama to Senators Max Baucus and Ted Kennedy. The letter extends the remarks that the president made yesterday, which came close to endorsing Rockefeller’s bill. Writing to Kennedy and Baucus, the President indicated that the administration could find another $200 to $300 billion for health care reform, linking that proposal to “giving special consideration to the recommendations of the Medicare Payment Advisory Commission” (MedPAC), “a commission,” he noted, “created by a Republican Congress . . . Under this approach,” the president continued, “MedPAC’s recommendations on cost reductions would be adopted unless opposed by a joint resolution of the Congress. This is similar to a process that has been used effectively by a commission charged with closing military bases, and could be a valuable tool to help achieve health care reform in a fiscally responsible way.”

These savings, he added, “will come not only by adopting new technologies and addressing the vastly different costs of care [in different parts of the country], but from going after the key drivers of skyrocketing health care costs, including unmanaged chronic diseases, duplicated tests, and unnecessary hospital readmissions.”

Giving MedPac the Authority to Take the Politics Out of Fees for Doctors & Hospitals

Under Senator Rockefeller’s bill, MedPac would have the authority to set reimbursements for doctors and hospitals. As Rockefeller explained in a recent Senate Finace Committee meeting: “I think that [this is] the best way to take politics out of all of this is to take Congress out of the setting of reimbursements for doctors under Medicare and Medicaid and for hospitals, because there is a group of 17 . . . completely dispassionate people,” who could do this, Rockefeller explained, referring to MedPac.

“And I think one of the [reasons] you have your $700 billion of wasted money every year,” Rockefeller added, “is the fact that there are too many political judgments made because there’s too much lobbying and Congress can — you know, unless they’re all health care experts, can fall victim to that. So the idea of MedPAC having the power to set those fees, reimbursement fees, to me is enormously attractive, takes politics right out of it and takes Congress right out of it.”

At the hearing, White House budget director Peter Orszag indicated circumspect support for Rockefeller’s bill: “Your idea of — I think we’ve referred to it as MedPac on steroids, or a much more powerful role for a body that is widely respected– is one approach.”

What Exactly Does MedPac Recommend?

Until now, most reform advocates have ignored MedPac. The reports that the independent advisory panel issues in March and June of each year are long. They are dense with detail. And they are very, very smart. The commissioners understand that health care quality could be higher if we spent less on care.

They have digested the Dartmouth research revealing that when patients in some parts of the country receive more aggressive and more expensive care, outcomes often are worse. They realize that doctors and hospitals should be rewarded for the quality of the care they provide, not the quantity. As HealthBeat has reported, they know that the fee schedule that Medicare now follows favors specialists while underpaying primary care physicians, and they have suggested re-distributing Medicare’s dollars “in a budget neutral way”– hiking fees for primary care while lowering fees for some specialists’ services. They have pointed out that some very lucrative procedures appear to be done too often, in part because they pay so well. The Commission has advised targeting these procedures and comp ring them to alternative treatments—just in case a less expensive approach might turn out to be more effective (and not as risky for the patient), as pricier, more aggressive treatments.

Finally, MedPac notes that some hospitals actually make a profit on Medicare’s payments. This is because these hospitals are more efficient: patients typically spend fewer days in the hospital and see fewer specialists. There are fewer readmissions, And generally, outcomes are better. MedPac suggests that when private insurers pay hospitals more, they may simply be rewarding less efficient hospitals for lower quality care. (And of course, private insurers pass those higher payments along to their customers in the form of higher premiums.)

MedPac goes beyond looking at how we pay providers. Investigating Medicare Advantage, it has described the care that private insurers are providing as somewhere between “disappointing” and “depressing.” Taking a look at the boom in hospital construction, MedPac noted, in its March 2008 report that “much of the added capacity is located in suburban areas and in particular specialties, raising the possibility that health care costs will increase without significantly improving access to services in lower income areas”. (Here, I can’t help but think about the current controversy over whether Hackensack University Medical Center should be building a new for-profit facility in a nearby suburb.)

As for the drug industry, in its June 2008 report to Congress MedPac observed that “researchers have shown that bias in industry-sponsored trials is common.” Because we lack disinterested, “evidence-based” information about new products, MedPac noted “we do not know which treatments are necessary for which types of patients. Guidelines do not exist . . . to delineate how much care is typically needed . . . and when patients are unlikely to improve with additional treatment.” In the same report, MedPac cast a cold eye on just how quickly we adopt bleeding-edge medical product and procedures to treat “most common clinical conditions” without “credible, empirically based information” to tell us “whether they outperform existing treatments and to what extent.” In other words, we need unbiased comparative effectiveness research. Those who make a profit on new products and procedures should not be involved.

These are exactly the radical but truthful recommendations that would make any well-paid health care lobbyist shudder. No wonder the Bush administration ignored MedPac’s advice for eight years.

Now, a new White House is taking MedPac’s recommendations to heart. And Congressional leaders also seem to recognize the link between Medicare reform and national healthcare reform. In April, HealthBeat reported that Senate Finance Chairman Max Baucus had declared that Medicare would become “the big driver” behind national health reform. Now, it’s becoming clear what Baucus meant.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the healthcare system, and the increasingly influential HealthBeat blog, one of our favorite health care reads and where this piece first appeared.

Do the Dems Have the Money to Pay for Reform?

Jun 5, 2009• 9

By ROBERT LASZEWSKI

Robert Laszweski has been a fixture in Washington
health policy circles for the better part of three decades. He
currently serves as the president of Health Policy and Strategy
Associates of Alexandria, Virginia. You can read more of his thoughtful
analysis of healthcare industry trends at The Health Policy and Marketplace Blog.

If I knew anything about computer graphics I'd post this really neat picture of a meter–sort of like a your car's gas gauge.

The full point would represent the cost of a health care bill–somewhere in the $1.2 trillion to $1.5 trillion range.

Each time someone put up scoreable savings I'd post it toward achieving the ultimate objective.

So, you will have to imagine my meter.

Here's where I think we stand today.

First, the President's original budget proposing to cut $309 billion over ten years from providers–including a lot from Medicare HMOs and elder care providers–looks to me to be on track to end up in any final bill and scoreable.

So, I feel pretty confident about posting $309 billion on my health care reform meter–the tank is about a quarter full.

Michael Porter–seduced, converted, or bludgeoned into accepting reality?

Jun 4, 2009• 34

By Matthew Holt

What a difference a few years makes. Michael Porter is the Harvard Business School prof who charged into health care a few years back. He (with Elizabeth Teisberg) wrote a book called Redefining Health Care which suggested how all kinds of changes on the delivery side of health care would solve all of our problems. Those changes were not exactly secrets to people who, say, read Michael Millenson’s Demanding Medical Excellence—a much better book written ten years earlier which explained why radical change on the delivery system side wasn’t going to happen. The answer?

It’s the Incentives, stupid.

Calendar: NIH Conference on the Future of Telehealth June 25-26, 2009

Jun 4, 2009

The National Center for Research Resources (NCRR) at the National Institutes of Health (NIH), in collaboration with Internet2 and the American Telemedicine Association presents: The Future of Telehealth: Essential Tools and Technologies for Clinical Research and Care

This two-day event will bring together stakeholders from government agencies, academic institutions, health care organizations and technology companies to:

Review the state of telehealth science and technology
Identify gaps in knowledge that can be addressed through targeted research and evaluation initiatives
Explore ways to leverage evolving information and communication technologies to advance the field

Catalyzing the app store for EHRs

Jun 4, 2009• 13

By STEVE DOWNS and JOHN LUMPKIN, SVP, Health Care Group, RWJ Foundation

Dr. Lumpkin serves as director of the Robert Wood Johnson Foundation’s Health Group, where he is responsible for planning and program management. Prior to joining RWJ, Dr. Lumpkin led the Illinois Department of Public Health for 12 years. As assistant vice president, Downs plays a leading role on the Foundation’s Pioneer Portfolio team. During his tenure at the Foundation he has created, developed, or overseen the Foundation’s investments in such key initiatives as Project HealthDesign, InformationLinks, the Health e-Technologies Initiative, the Public Health Informatics Institute, Connecting for Health, and Common Ground. His writings may be found at Pioneering Ideas, where this post first appeared.

Recently, Steve posted about the idea, floated by Ken Mandl and Zak Kohane, that EHRs (or health IT more broadly) could move to a model of competitive, substitutable applications running off a platform that would provide secure medical record storage. In other words, the iPhone app model, but, for example, you could have an e-prescribing app that runs over an EHR instead of the Yelp restaurant review app on your iPhone. We’re thinking about the provider side of the market here, as Google Health and Microsoft HealthVault are already doing this on the consumer side.Continue reading…

PHRs, The Model T, Meaningful Use and the Patient-Centric HIT Revolution

Jun 3, 2009• 7

By BOB COFFIELD

There is a growing discussion on the health consumer-centric (patient-centric) meaning of “meaningful use” of EHRs and health information technology. Jane Sarasohn-Kahn summarizes this discussion in her recent post, “Meaningful USe – or, whose health is it, anyway?” at Health Populi where she reflects on Ted Eytan’s post, “Is it Meaningful If Patients Can’t Use It?”

Since Ted’s post other health care thought leaders have offered their comments. A list of these individuals can be found in Jane’s post. As Jane mentions, this topic was central to much of the discussion that occurred during the first two days of the testimony before the National Committee on Vital and Health Statistics (NCVHS) on the Future of Personal Health Records held on May 20 and 21. The discussion will continue at the NCVHS hearing on June 9 when there will be a panel focused on “Consumer Advocates and Attitudes” that will include Susannah Fox, Dave deBronkart, Deven McGraw, JD and Robert Gellman, JD.

Jane mentions in her post our testimony before the Subcommittee on Privacy, Confidentiality and Security of the National Committee on Vital and Health Statistics (NCVHS) on the future of PHRs. Our panel, including me, Jane and Daniel Weitzner, the W3C Technology and Society Policy Director, opened the hearings on PHRs. Our role as the opening panel was to try to set the stage for the context of the discussion on the future of PHRs and consumer facing health care information technology.

As the opening speaker at the hearing I decided to stay away from immediately diving into the legal issues and instead give the committee a landscape view of where I think we are in the history of health information. My goal was to provide a historic framework for PHR development by drawing some historic parallels to the history of the development of our transportation system. By analogy I compared today’s PHRs to the Model T era of the automobile area and taking a page from Dave deBronkart told the committee my personal family e-health information story. Below is a complete copy of my written testimony submitted to the committee.

As the discussion continues on “meaningful use” the role that PHRs play is important. Focusing on health care consumers and their practical use of PHR tools is vital to the future of our health care system. As I said in my testimony there will be game changers but we need to see the potential of today’s Model T PHRs and build toward the Prius Hybrid PHRs of the future.
Prepared Statement for Subcommittee on Privacy, Confidentiality, and Security National Committee on Vital and Health Statistics (NCVHS)

Discussion on the Future of Personal Health Records

Good morning. I want to thank the Co-Chairs, Subcommittee and Committee Staff for the opportunity to participate in today’s discussion on the current state of the personal health record (PHR) and the future use of this and other health care technology tools by the health care industry and the health care consumer.

My name is Bob Coffield. I am a health care attorney from Charleston, West Virginia, with the law firm of Flaherty, Sensabaugh & Bonasso, PLLC. I have a broad-based health care practice, providing legal and business services to a variety of health care clients. A large portion of my practice focuses around health information issues, regulatory compliance, privacy, security, and health technology. Over the past five years, I have become involved in the social media movement, and that involvement has changed the way I live, work, collaborate and communicate. My involvement and interest in the social media movement and its impact on our lives has led me to focus a portion of my practice on legal concepts and issues generated by the use of social media tools and technologies in health care, law and other industries.

Introduction: Today’s PHR is the Model T

As the opening speaker, I want to set the stage for today’s discussion on the questions raised by the committee. As the committee examines the issues, I recommend that you look toward a longer horizon of 20 to 50 years. In this age of information and accelerating technology, it is often easier to predict what may happen in 50 years than what will happen next year. As information technology advances and new technologies are developed, it has become more difficult to conduct short-term strategic planning in the three to five-year range. Over the past 10 years of the maturing information era, we have seen incredible advances and significant disruption in all business, including health care.

At its center, the information age is characterized by the ability to create and transfer information and knowledge freely and to have instant access to knowledge that would have been impossible, difficult or too expensive to find in the past. Jane Sarasohn-Kahn and others today will provide the Committee with an understanding of the current health care consumer marketplace and the major motivators driving health care consumer empowerment in the information age, and also will provide a perspective on the current state of consumer engagement in health care. It is my belief that this changing era is having a profound impact on today’s health care industry. The strategies, systems, approaches and governing rules used today and by past generations may not be successful in today’s and tomorrow’s changing information era.

A part of today’s process should be to consider what the long-term goals are for health information technology, including the PHR, and how it can be used to drive consumer-focused and controlled health care in the information age. Along with this discussion, we have a responsibility to talk about why involvement of the consumer matters and what impact it will have on improving care, reducing costs and creating efficiencies in the health care system.

As we discuss health information technology and PHRs today, we have a responsibility to stay focused on this question: “What will improve the quality of care for you and me, as consumers of health care?” This single question needs to remain at the center of today’s discussion and the continuing debate on consumer health information technology. As the health care industry becomes more and more specialized, complex and technologically advanced, we often lose sight of the purpose of the health care system. That purpose is human care and compassion. You and I, as health care consumers, must remain at the center. My hope is that the future of our health care system will use technology, including PHRs, to improve the human experience and interaction between the professional caregiver and health care consumer.

The questions I often struggle with and hope to hear discussion on today are: How will PHRs drive consumer empowerment, and how will this consumer empowerment lead to improving care? We can all sit around and discuss the best ways to build PHRs, but the questions remain whether or not the health care consumer will be attracted to use PHRs and whether providers will be willing to incorporate PHRs into the treatment and care process.

As I said at the opening of my remarks, I want to set the stage for the discussion and testimony today by sharing a story and painting a historical perspective. As I looked over the agenda of those speaking today, I was struck by the level of experience and diverse backgrounds that each of us brings to the discussion. However, because of the level of specialization represented in this gathering, there is the risk of remaining deep in the weeds, dealing with details, and failing to step back and take a wider view of the landscape. The story and analogy I want to share with you is my attempt to take you on a tour of that broader view.

I am a believer in the adage that history repeats itself. What we are trying to do today is to provide you with a perspective and prediction of the role that the PHR will (should) play in the health information technology infrastructure over the next 10 years. So a historical sketch of where we have been and where we are is valuable to the discussion of where we may go.

I want to start the story with a quote from the 1800s, by inventor Oliver Evans, as he spoke about the future of the transportation system in the United States.

“The time will come when people will travel in stages moved by steam engines from one city to another, almost as fast as birds can fly, 15 or 20 miles an hour . . .

A carriage will start from Washington in the morning, the passengers will breakfast at Baltimore, dine at Philadelphia and supper in New York the same day . . . .

The 1800’s saw the dawn of the railroad system in the United States, as a result of the development of the steam engine. These developments led to the widespread use of trains as a mode of transportation for a growing population that, until that time, had been relatively immobile. The growth of the railroad system started at the local level, grew to regional connections and ultimately led to a national network of railroad tracks from east to west and from north to south. Prior to this time, personal travel required one to travel on foot, by horse or by carriage.

My ancestors, who grew up in the hills of northern West Virginia, came to West Virginia (then Virginia) in the late 1700’s. As we say in West Virginia, “they lived out on the ridge.” A number of generations went by, and there was little mobility of my family. They lived out their lives on those same ridges for well over 150 years. They raised their families and farmed. They lived a relatively isolated and stationary life. Traveling beyond a few miles was difficult, impractical and largely unnecessary, at least from their perspective of the world.

However, by 1900, the landscape had changed, and the Industrial Revolution was having a profound impact on the world. My great-grandfather and grandmother had two sons who were teens in the 1890s. In the 1890s, my great-uncle went to college, came back and taught school for a few years and then went on to law school. Likewise, my grandfather went to college, came home like his brother to teach school for a few years, and then continued on to medical school in Cincinnati, Ohio – at that time a long distance from the northern part of West Virginia. He came back and practiced medicine in Wetzel County, West Virginia, from 1911 until his death in 1936. He saw home patients initially by horseback, and then in 1915, he traveled to Pittsburgh, Pennsylvania by train to pick up a brand new Ford Model T, which replaced his horse in his rural medical practice.

As the rail system in the United States matured, it grew into a more complex mass transportation system. Individuals who, prior to that time, had used their own modes of transportation, whether on foot, by horse or carriage, started to rely upon the system for transportation. They became passengers who didn’t own the train or the rails. As the railroad system developed, we saw issues related to standards, such as the gauge of tracks. Local, state and federal government become involved in furthering the growth and expansion of the railroad system by providing financial support, political influence and regulatory assistance to the growing railroad industry.

At that stage in history, no one in the powerful railroad industry would have predicted the disruptive influence by a young, different type of engineer – Henry Ford. With the advent of the automobile and the mass production of the Model T in 1908, our transportation system in the United States was forever changed. Over the next 20 years, the adoption of automobile travel was unprecedented. This revolution led to a demand for better roadways and improvement of the largely privately built turnpike roads. The Federal Highway Act of 1921 authorized the Bureau of Public Roads to provide public funding to help state highway agencies construct paved systems of highways, and this led to the Federal-Aid Highway Act of 1956, which authorized the creation of the Interstate Highway System.

By analogy, we can compare the development of the transportation system to the development of today’s health information system and draw many comparisons and parallels. The health information system, up through the 1950’s and 1960’s, was paper-based, centrally located and uncomplicated. The medical record system for my grandfather’s practice – to the extent that it was used – was simple. Likewise, the medical record system and documentation used by my father and uncle during their medical careers, roughly 1940-2000, was relatively non-complex. During this time, there was little specialization: Physicians were generalists in everything. In large part, physicians from this era cared for their patients from birth to death and, in the case of my grandfather, father, and uncle, cared for multiple generations of families. Providers during that time had a relatively comprehensive picture of the medical history of each individual, as well as that individual’s immediate and collateral family members. Prior to specialization in health care, we had a health system focused on the individual patient, and health information was centered on that individual and the individual’s family.

By the 1970’s, we saw the development of the first electronic health record – the problem-oriented medical record (POMR), predecessor of today’s current Electronic Health Records (EHR) and Electronic Medical Records (EMR). At this same time, we saw the expansion of medical litigation, which has played a significant role in the health information system over the past 30 years.

Prior to 2000, little had been written or heard about PHRs. Back in 2001, in a report called Strategy for Building a National Health Information Infrastructure, the National Committee on Vital and Health Statistics mentions PHRs and the growing consumer use of Internet-based health information services. This was important because it was the first time that a national health body acknowledged or officially recognized PHRs. In 2005, the American Health Information Management Association (AHIMA) formed a work group to examine the role of PHRs in relation to EHRs, and the pace and interest in PHRs has continued to increase since that time.

Over the last year, interest and activity in the development and use of PHRs has accelerated. This new-found interest has now culminated in the first law directly regulating PHRs and PHR vendors, under the Health Information Technology for Economic and Clinical Health Act (HITECH), which is a part of the American Recovery and Reinvestment Act of 2009, signed into law on February 17, 2009.

How is the history of our transportation system analogous to our health information system? On a basic level, both provide transportation – one transported humans, and the other, human information. Both started as uncomplicated systems that were not interconnected. I imagine you are already formulating other parallel points between these two systems.

To begin today’s discussion on PHRs, we need to examine where PHRs fit in this historical perspective and timeline. What is the equivalent of the PHR in the history of our transportation system? Today’s PHR is the equivalent of the Ford Model T. The PHR will be the vehicle to individually transport health information in the future, introduce the involvement of consumers in their own health information and wellness and inspire a time of innovation and creativeness over the next five to 10 years. If the age of the PHR takes off, it will bring about a wholesale change in the way that health information technology is structured and will radically disrupt traditional health care industry models.

There are various other analogies to be drawn between the two historical perspectives. For example, do the trains and the rail system represent the traditional health care providers and payors in the industry who are maintaining data in silos and segregated systems? Can we draw comparisons between the powerful railroad industry versus the nascent auto industry and the current health care and insurance industry and the emerging Health 2.0 technology movement? Are the disagreements that occurred in the railroad industry over the gauge of railroad tracks analogous to the debate occurring over the need and process to develop standards for health information technology? Can we draw parallels between our country’s development of a national network of railroads through local, state, and federal initiatives to those ongoing efforts by state health information exchanges (HIEs), regional health information organizations (RHIOs) and the national health informational network (NHIN)? Will there be similarities between the freedom that consumers felt the first time they bought an automobile and drove it down the road and the feeling of empowerment experienced when a health care consumer adopts and uses a PHR? In the coming years, will the connecting of EHR and EMR systems and the development of the NHIN be relegated to being used to transfer bulk health data, not unlike the role that the railroad system plays today?

As we look toward the future of PHRs, we have to understand that we are now looking at the Model T stage of PHRs: Call it PHR 1.0. The PHRs of the past 10 years and, in large part, the PHRs of today, are still relatively rudimentary and impractical, not unlike the first automobiles. I suspect my grandfather’s experience of traveling to Pittsburgh by train, having never owned a car before, to pick up his new Ford Model T and drive it back into the hills of West Virginia, was not unlike Dave deBronkart’s experience when he set up his Google Health account and imported his own health information from his providers. Prior to their experiences, neither knew how to drive the vehicle, but they learned in the parking lot. Once they both bought into the product, they didn’t have any good roads to drive on, and when the vehicle broke down they had to fix it themselves. However, through their efforts the world began to change, and their lives were and will be forever changed.

Over the next five to 10 years, and probably longer, we may see PHRs become the multi-colored, sleek-designed, more powerful automobiles, analogous to the golden era of the automobile industry from 1940 to 1950. Continuously over that time period, new personal options will be developed as add-ons to the PHR. As PHR adoption grows, we will have to develop larger, longer and more robust highway systems to allow for the transfer of health data by and between PHRs. Likewise, new standards will come into existence, not unlike those adopted by industry or those created by government. Safety features also will be developed continuously to protect and secure the health information maintained, stored and transferred through PHRs. Think of these as the modern-day innovation, adoption and enforcement of traffic signals, the use of seat belts and requirement for guard rails.

As we look toward the future, we also have to be aware that there will be game changers that we can’t envision at this time. Although PHRs might now be the industry solution to change the way we aggregate and store health information, new technology may be invented that disrupts this strategy and approach. For example, consider the impact that air travel had on the automobile industry. We must remain open to change in this new information era – change will be the norm and not the exception.

Using PHRs to Transform the Health Care Industry

The efforts by large technology companies and other Health 2.0 technology companies could transform the health care industry by triggering advancements in health information technology and laying the groundwork for overall health care delivery and payment reform. Although it is too early to say whether the PHR, in fact, will be the catalyst for health care reform, the Committee, government and the larger health care industry and community need to understand and explore PHRs and their role and consider how the consumer-focused PHR revolution will impact the health industry.

A convergence of factors could cause a comprehensive shift in the way health information is stored and used. Innovations in health information management technology are altering the way that patients, health care providers and payers maintain, use, control, and disclose health information. Through such technology, the current, decentralized system of records maintained by multiple providers and entities at multiple locations – often with conflicting and duplicative information – is being transformed into a centralized record maintenance system that may rely on personal health information networks (PHIN), where the PHR serves as the central repository for health information shared through a system of developing regional or national health information exchanges. Vince Kuraitis of the e-CareManagement Blog calls this change a “transformation from Industrial Age medicine to Information Age health care.”[1]

This transformation in the way information is maintained, stored, and exchanged empowers the health care consumer by offering a new level of control and responsibility over his or her care. It will directly impact the patient-provider relationship.

The traditional model for maintaining medical records, in which the provider of care stores, maintains, and updates the record, is based upon the need to provide continuity of care. The medical record reflects the plan of care, documents the care provided, and records communications among providers. Also, the medical record assists in protecting the legal rights and interests of both consumers and providers.

In the 21st century, our health care system simultaneously has become more fragmented and specialized, on one hand, and more coordinated and wellness-focused, on the other. Health care consumers have become mobile and now seek the services from a variety of providers engaging in numerous specialties. These same consumers change providers on a regular basis and take advantage of new models of care, like urgent care services, to complement traditional primary care services. The increasingly mobile population has caused breakdowns in continuity of care. As individuals move from city to city and state to state, they leave behind a trail of partial medical records – some on paper, some electronic – with various providers, insurers, and others.

The increasing popularity of EMRs, EHRs, RHIOs, and HIEs signals a need to address the increasing complexity of maintaining and sharing these different types and silos of health information. The PHR may be the disruptive technology that provides a simple alternative to ongoing efforts to create an interconnected network of interoperable health information systems with detailed querying functions, capable of making accessible in one place the health information and continuity of care record for individual consumers. In contrast, PHRs would travel with health care consumers and provide a central location for information regarding the consumers’ individualized needs.

Ownership of Health Information

The shift to a consumer-controlled PHR from a provider-based and controlled medical record raises traditional property law issues. As health information becomes increasingly networked and technology permits health information to be transferred more easily, the lines demarcating ownership of health information become further blurred.

Health information is often viewed under the traditional notion of property as a “bundle of rights,” including the right to use, dispose, and exclude others from using. This legal application of historic property law may not be well-suited to the information age, in which patient information is shared through a variety of formats, copied, duplicated, merged, and combined with other patient records into large scale databases of highly valuable information.

Who owns health information? The physician? The insurer? The health care consumer? Under the traditional theory, providers own the medical records they maintain, subject to the consumer’s rights of access in the information contained in the record.[2] This tradition stems from the era of paper records, where physical control meant control and ownership. Provider ownership of the record is not absolute, however; HIPAA and most state laws provide consumers with some right to access and receive a copy of the record. Health care consumers have received other rights out of the bundle of property rights, including the right to request corrections to their medical information and the assurance that such records are maintained confidentially.

The PHR model, where all records are centrally located and maintained by the consumer, flips and realigns the current provider-based ownership model of managing health information. Instead of provider-based control, where the provider furnishes access to and/or copies of the record and is required to seek patient authorization to release medical information, the PHR model puts the health care consumer in control of his or her medical and health information.

[1] Vince Kuraitis, E-CareManagement Blog, Birth Announcement: the Personal Health Information Network, March 8, 2008, http://e-caremanagement.com/birth-announcement-the-personal-health-information-network-phin/.

[2] Alcantara, Oscar L. and Waller, Adelle, Ownership of Health Information in the Information Age, originally published in Journal of the AHIMA, March 30, 1998; http://www.goldbergkohn.com/news-publications-57.html.

Bob Coffield is a health care lawyer who writes the Health Care Law Blog, where this post first appeared.

Should We Open the VA to All Comers?

Jun 3, 2009• 34

By MERRILL GOOZNER

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. Until March of 2009, Merrill directed the Integrity in Science project at the Center for Science in the Public Interest. His first book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at Gooznews.com,where this post first appeared.

Public plan proponents point to Medicare and its low administrative costs as their primary argument for why a similarly-structured public insurance product, offered through a Massachusetts-style insurance exchange (the connector), would dramatically lower health care costs. Not so, says blogger and health plan consultant Joe Paduda, who offered a persuasive rebuttal on the Campaign for America’s Future website last week. Joe made the following points:

1) Medicare has no underwriting or sales expenses or marketing costs. No commissions, either. This saves a lot of admin dollars. This differential would disappear in a health connector-type system, with the playing field leveled by dramatically reducing commercial healthplans’ marketing costs and elimination of their underwriting expense.

2) Medicare has one-time enrollment and dis-enrollment, and greatly simplified eligibility processes. This cuts their costs, but would not continue under a connector model.

His solution? Make the public plan an extension of the Veterans Administration, which he points out has lower costs, higher quality, higher patient satisfaction and lower utilization rates than virtually every other public or private insurance plan.

Good points. But what Paduda failed to note was that the VA also is a single-payer-type system that delivers health care directly, just like the British National Health Service. All its physicians are salaried; it owns its hospitals and clinics. The problem with using the VA as a model for the public plan is that those who would accuse its proponents of advocating for “government-run health care” would be right. How many of those proponents would be willing to stand up and say at that point: “Yes, that’s what we’re for.” Even Physicians for a National Health Plan over its more than three decades of advocacy for a single national health payer (“Medicare for all”) has never called for nationalizing the provision of care.

The Infrastructure Chronicles

Jun 3, 2009• 8

By PAUL LEVY

Paul Levy is the President and CEO of Beth Israel Deconess Medical
Center in Boston. He blogs about his
experiences at, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

A recent Boston Globe story
by Stephanie Ebbert about squabbling between two state agencies
involved in the rehabilitation of a local bridge has prompted me to
start a new occasional series on this blog. People who don't know about
my lives before health care may not know that I am an infrastructure
junkie. For reasons my daughters consider very odd, I love roads,
bridges, sewage treatment plants, electricity cables, and the like. If
you are not interested in this topic, stop reading, but from time to
time, I'm going to relate stories to you about this field, but mainly
positive ones, where creative public officials and others have made the
fabric of urban life better for the public — in ways that never, ever
make the newspapers.

Here's the first. Back in 1999 or so, I was
Administrative Dean at Harvard Medical School. Connie Cepko, one of our
faculty members, called one day. Her complaint: Riding to work on her
bicycle every day, she noticed that the Longwood Avenue bridge over the
Muddy River and the MBTA tracks was full of dangerous potholes. What
could I do about this, she wondered.