Posting in Government
You expect perfect security, perfect privacy, and perfect performance from medical solutions. The industry tries to give it to you, but in the process it isolates itself, rendering everything proprietary and expensive.
A half-dozen years ago I began looking at applications, based on WiFi, that might live in the air.
I saw home automation applications. I saw inventory applications (so you can find your stuff) and I saw a host of medical applications, which I called the "killer apps."
(Picture from Microsoft HealthVault.)
Those days are not yet here.
Medical device makers are tiptoeing toward wireless, but they insist on using frequencies dedicated to their devices. As hospital use of WiFi increases they want devices in nearby frequency bands, like cell phones, banned.
This is not the only area where medicine resists open standards.
- Health IT vendors remain mired in the 1970s, leading some to compare the President's efforts to modernize the sector to Vietnam.
- Major vendors remain wedded to CPT codes, controlled by the AMA, that are proprietary and thus prevent the adoption of open source and open standards.
- Insurers refuse to support solutions based on PC technology, requiring that they be divorced from other functions.
It's a stupid shared by the entire medical-industrial complex -- doctors, hospitals, insurers, vendors, government. Medical solutions must be dedicated, they must be unique, they must be single-taskers, they must be proprietary.
So who is to blame for this state of affairs? After years of research I have an answer.
You expect perfect security, perfect privacy, and perfect performance from medical solutions. You expect audit trails on your medical records that make integration impossible. You expect perfection, and the industry tries to give it to you, but in the process it isolates itself, rendering everything proprietary and expensive.
This is an attitude that will be hard to beat back.
The government's health reform agenda includes a commission that will recommend efficiencies in Medicare, which could include use of PC standards. The committee defining "meaningful use," a key to gaining stimulus cash, has so far resisted industry efforts to mandate proprietary solutions, but the battle is not won.
In fact that battle has just begun.
Every industry, as its use of computing matures, eventually moves toward industry standards. It happened in law, it happened in manufacturing, it happened in publishing.
It has not happened, yet, in medicine.
But if you really want the cost curve bent downward, you should demand that it does. You can do that regardless of whether you're liberal or conservative, Republican or Democrat. Want true bipartisan health reform? Industry standards are where it's at.
You can start that effort by supporting Personal Health Records (PHRs) like those of Google Health or Microsoft HealthVault, and stop whinging that "Google wants to sell your data" (or that Microsoft does). They don't. They have said they won't by contract. Those who refuse to accept this have an agenda and (I believe) they don't have your interests at heart.
By supporting PHRs, you support your right to your own data. You support liberating data from proprietary systems and placing it under industry standards. You support integrating your health with the world of the Web, and the benefits such industry standards can deliver to you.
So what about it?
Sep 20, 2009
Thanks for writing and for all your good points. CCHIT used HIPAA requirements and AMA standards to keep other companies out of that business for many, many years. One important proposal from the people at Sermo is to get rid of the AMA as a gatekeeper because they charge for their codes, making creation of a truly "open source" solution impossible. I don't know what to do about the Haties. Their whole worldviews were turned upside down and so they do what George W. Bush did -- talk louder and see everyone else as an intractable enemy. Maybe the left needs an Agnes...
First, just a little comment on your (Dana's) main article: You expect perfect security, perfect privacy, and perfect performance from medical solutions. You expect audit trails on your medical records that make integration impossible. You expect perfection, and the industry tries to give it to you, but in the process it isolates itself, rendering everything proprietary and expensive. This is an attitude that will be hard to beat back. Are you suggesting that something less than perfect privacy and perfect performance is the only alternative to proprietary solutions? I'm sure that sufficiently strong protocols can prevent any cross-contamination of information between the medical systems and the other devices on the networks. W/r the wingnuts that equate standards with "socialism," they should remember that the Internet and the World Wide Web and email wouldn't exist without the use of standards. Just by using the English language, they're accepting the reality that you can't communicate without using some sort of standard. You can't exercise your unfettered "freedom" to create your own language. There are times and places when communal solutions are the better choices.
Good work, Dana, thanks for staying on this subject. I wonder how many people are opposed to ?standards?; one would hope not many. But the demagogues seem to be particularly effective at spreading ?misinformation?! I retired last year, after more than 40 years as a computer systems analyst; many of the objections to integrating computing into ?medicine? are just absurdly ridiculous! ?computing? continues to be more & more integrated into business and everyday live, except when it comes to health care. Hopefully, this time, the opposition will be pushed aside; for the good of all (including the misguided ?opposition?).
You should rid yourself of that illusion. Insurance companies, worker's comp companies, other doctors and so forth have access to your records. They are not private. However, if YOU want to look at your records, you play hell trying to get teh doctor to release them for your perusal in the office. They are really CYA documents for your practitioner.
jrlambert - Sorry. I should have changed the title in the last post, rather than taking the default value. I have nothing against standards. In fact I'm sure that the local physicans' office I was talking about (a real world example) incorporates numerous. Sorry for the confusion.
Many countries do perfectly well driving on the left. It is obviously tyrannical for the government to put people in jail for doing it in the US. Of course, for the insurance companies to deny you cover unless you pass their driving tests (each company different) would be fine, because it involves a free contract between equal players.
Mikifinanz: A lot of the economic and political debate I read these days seems like it's out of the 1890s. That was also an era where many people felt that all-powerful private interests were pulling the strings on power and depriving people of their rights under democracy. But that isn't how it went. The Populist storm was followed immediately by the Progressive Era. Those who think that change is impossible should not give up on it. That's the lesson history teaches us.
Wow! Someone confusing the observation that "standards are needed" ..... with a range of political agendas... Nearly any reasonable standard will work.. as long as it is put in place. And if there are problems/limitations in the standard.. they can be addressed... in a unified manner if the standard is excepted. And , yes, there are some standards with less than honorable / open agendas attached to them. But without some broad level of acceptance .. all successes will be limited to a small communities and small countries. In electronics, engineers often joke... "standards, we love em.. that's why we have so many!" On a more serious note: Too many people today thinking that "passionate" debate requires shouting and hatred towards opposing views. Debate - good... ( to review all the issues) Manners and civility - good...( to allow the acceptance of ideas on their own merit - not based on who presented them) Shouting and hatred - bad... This "passion" only prevents ANY solution from ever being given a chance to succeed. If your only tool is a hammer ... all your problems start looking like nails.. If your only thoughts are based in anger... all your solutions start with requiring anger.... Very few examples of this attitude helping create solutions in any endeavor ...........except war.
The politicians are co-opted. While all the sound and fury is going on in the press there are hundreds of lobbyists in hundreds of offices in Washington twisting arms, offering money for re-election bids and making any number of threats or promises to get their clients in the health related mega-corps protected from any serious harm to their bottom line. We the average citizen will get screwed either way, we don't have lobbyists and have lost control over the processes that run government.
I hadn't heard that one before. Very cute. It reminds me of a completely non-political point. Millard Fillmore was the Know-Nothing candidate for President in 1856. Have you seen this humorous fake biography of him? http://www.amazon.com/Remarkable-Millard-Fillmore-Unbelievable-Forgotten/dp/0307339629/?tag-nosimacluecom Of course if you really want to be entertained by Know Nothingism, you can't do better than Daniel Day Lewis in "Gangs of New York."
Wow! The "no" nothings sure jumped on this right away at the beginning. I live in a small town (about 5000) and our physicians' office has been wireless for 5-7 years now. The doctors and their assistants all use netbook-sized units for nearly everything. No intermediate paperwork. Usually the only paper I (as a patient) see is the sign-in sheet at the beginning and the statement at the end. Prescriptions are sent directly to the local pharmacy of our choice, or a hardcopy can be printed for mail-in scripts. So I'm not buying the line that we can't do it. This is America. It used to be the case that anything was possible. Now we seem to have a group trying to tell us that we can't. Sheesh!
The role I like best for government is in directing market incentives toward solutions, and not just to monopolies or bigger problems. The reason health care costs jump every year is because market incentives cause them to. Those incentives must be changed, but the market won't by itself because the market profits from them. Only government can transform incentives. It has been doing this since the Erie Canal. This is at the heart of AntiTrust law. Don't give me that guff about socialism -- we're talking about 200 years of American jurisprudence, and prudent action by Congress, the executive, even some states. Capitalism is great, but it needs to be channeled by democracy in order to be at its most efficient. History shows that. There is an enormous difference between regulating markets so executives aren't at risk of jail from common actions, or so that there are incentives to do what society wants, and government owning the means of production. This is a difference that has been blurred out by the propaganda of our time, and it's time to call the propagandists on it.
Wow, where does this "socialism" garbage come from? Most of these people have no idea what socialism really is. I live in the Middle East, with a King no less. Definitely not socialist, and not considered a part of the developed world quite yet either. However, the hospital that we go to has a system integrated among all our doctors, the pharmacy, and the hospital. The doctor can pull up online the x-rays or exams done in other parts of the hospital, review the records right there and send the prescription to the pharmacy. Additionally, the hospital system will print up all my records and hand them to me at my request, no charge. Pretty sad I can't get this type of efficiency in the US. Even more ridiculous that such standardization is called "socialism." These right wing nut jobs are probably still using leaches for "bad humors."
Here's another highly successful model - TRICARE Reserve Select (TRS). Everything is done online and provides a single payer option but managed by independent federal contractors depending on the location of the military service member being insured. Granted, health care electronic records are still managed locally by service member base hospitals in the same capacity the VA manages its member records. However, there has been a push by TRICARE to make all records electronic. http://www.defenselink.mil/news/newsarticle.aspx?id=55362
VA Takes the Lead in Paperless Care http://www.washingtonpost.com/wp-dyn/content/article/2007/04/06/AR2007040601911.html I am following up on the results and geting a Dr's opinion so far.
Like Income Tax reform and nearly every other type of reform that has been tried (with the exception of Welfare reform) the matter of simplifying and making it fair for consumers will fail unless we can remove the sheer volume of regulation surrounding the entire industry. HIPAA is great for protecting the consumer but the costs associated with complying with the amount of laws, prevention of enormous lawsuits against doctors (aka tort reform), skyrocketing malpractice insurance, expensive consumer-based health insurance, lack of coverage and access, payoffs, kickbacks, and every other embedded cost has sucked the life out of the system. People expect top notch health care and expect their health insurance to cover whatever the procedure is but don't want to pay for it. You want a Cadillac but only want to pay Yugo prices. Keeping costs down involves much more than implementing better standards. It means simplifying the system and removing the lawyers from the equation to the extent possible to give more freedom to the consumer and medical industry at the same time as lowering costs to both groups. Doctors must be able to keep their practices and be encouraged to continue educating themselves on cutting edge medical sciences. Potential doctors must feel that the medical industry is worthwhile not only from a career path of helping others but also from a lucrative means to an end. However, if we jam more Government control into the middle of the problem we will end up with more laws and loopholes and lawsuits and complexity. Push this country into a Government-managed health care system and what we'll end up with is a bloated version of medicare and medicaid on the scale of the Federal Tax System. In the end, the middle class will bear the brunt of shouldering the cost of yet another social welfare program. Eventually, the middle class will be the lower class and the upper class will rule and that is what is can be found in ideologies like Fascism, Socialism and Marxism. The exception is we don't use those words anymore - now we use the word Progressivism and espouse entitlements that should otherwise be hard earned. Open standards is only a band-aid fix to a much larger illness this country faces.
For John and athrillofhope, they currently do this idea at VA. They have their own version of medical records, and every VA hospital uses the same version of medical records. The problem comes when a patient tries to get their own records from the VA and into the hands of a local doctor. Won't work, because they use different standards and its too much trouble to re-enter data from old records into the format the new doctor uses, so the new doctor orders a new batch of test, e-rays, etc. to start getting to know you. Guess who pays for those tests? You, or the taxpayers, depending on your circumstances. If the medical providers uses open standards you could pick up your records, hand them over to your new doctor, and she/he would be able to utilize them to start giving you accurate care right away, without the cost and delay of repeating tests. Your record information would be as secure as it is now, and you would actually be able to read the record, help determine the accuracy of the records, be better informed and able to be an active participant in your care. I agree with Donald...test and test and test several competing ideas and implement the best. Ready, fire, aim does work, in spite of sounding silly.
A column in the Washington Post offers a working model for health IT, and suggests that all efforts be made toward growing it. That model is VistA, the VA's health care computing system. For more check out ZDNet Healthcare today.
Having covered medical IT at ZDNet Healthcare I have become leery of the CCHIT criteria. They seem devoted to the interests of existing vendors, cementing a "big iron" approach that is immensely costly and has high barriers to competition.
Everything you fear the government "might" do, insurers are doing. And since they're monopolies they can get away with it. Or do you hop about the health insurance market like a butterfly, comparing policies and switching carriers every year? Pricing is set so you can't. Individual and small group policies are nearly unaffordable. Markets can take off when they have standards. The PC was a standard. So was IP. Why did IP succeed? Because government put a lot of money into growing it, telling carriers to forget about the money and concentrate on service instead of fighting with one another over minor proprietary tweaks. We have also seen this in the cell phone market. Say what you want, but the universality of GSM as an inter-country standard enabled portability and market growth in ways our carriers have not been able to match. What made the difference? Government. An over-reliance on ideology turned Marx's ideas for a "worker's paradise" into the Communist dictatorships of hte 20th century. Don't let your supposed love of Adam Smith do the same to you.
In the fury of throuwing rocks at healthcare (and I am not in favor of the current proposal) Let's do this task..... #1 job - if we don't like it - let's propose a working model that would work. #2; let's test it. #3; get out the bugs. Get enough scenarios tested so we know what the solutions will be in almost all cases. #4: implement it. No Problems - Only Solutions.
The way I see it, I already pay for insurance and do not get certain medications or services covered by that insurance. Even if I were to change my insurance, it would be the same store. So..here's a novel idea, GIVE THE CUSOMER WHAT THEY AREADY PAID FOR!!!
It's funny how everything nowadays is a certain march towards socialism. As a physician, I own (along with several partners) a business: a medical practice. But we would much rather deal with the government (Medicare) than private insurers. But that's another debate for another time. Regarding the standards for EHR (or PHR), it is true that they would help. Although we successfully implemented an EMR system in our practice less than a year ago, we have the resources to have full-time IT staff in our practice, so we can rely on them to keep us abreast on issues of interoperability that we as doctors know little about. As we start to connect more and more with each other, with hospitals, and then with the patients themselves, this will become increasingly complex. It's the small group and solo doctors that are being left out in the cold. So while we do accept some of the blame, we are also being dragged into the fray. It's like the pilot being told that the airplane's specs need to be changed and he needs to 'get with the program.' We're trying. Ultimately, it may take private industry to take the lead on some of these issues. Just like the CCHIT criteria, the government would rather someone else invest the time and money in something they can later approve of than to do the heavy lifting themselves.
"Who gains? The One World Governing authority, as it now has the power to "cut-off" any political dissident from purchasing food and shelter that it wants to." I wrote a sci-fi short story based on this premise over a decade ago. People were tracked/identified with embedded RFID tags that also had a minimal chemical analysis functionality to monitor a few things. They were looking primarily for certain patterns of thought, with an eye toward eliminating them. In fact in my story they had long been successful in eliminating "wrong thinking," (the title) and the system falls apart when someone comes along in the future and triggers a monitor. Nobody alive had seen such a thing and didn't know how to deal with it. As a result the fellow gets away, sans chip, and continues to pollute other people's minds, who are subsequently punished by the book, which is to shut off their purchasing power, they eventually starve to death. I have zero faith and trust in my fellow man to do the right thing, when organized under the mantle of "government."
Have the government try this experiment at the VA and with Medicare. When it works there, perhaps then we can discuss how it should be applied to the rest of us.
I don't care how you package socializing medicine, it is still shoehorning the government, "Big Brother," in between you and your doctor. And this "new" argument, using technology standards that centralizes your medical data and "frees" you from being "chained" to a single provider, SOUNDS great. But it is still the same old song: the government imposing some form of something on a private industry with the end result of less power in the hands of the individual and more power being consolidated by an ever greedier and growing Big Brother. Does your argument have a logic to it? Sure! As said, it SOUNDS great. But so does a cashless, One World Currency make sense--from the One World Government's perspective. Who looses there? Everyone. Who gains? The One World Governing authority, as it now has the power to "cut-off" any political dissident from purchasing food and shelter that it wants to. I'm just one of those people who knows what right and no matter what direction the world is going, will never just find it "okay." Power corrupts, and absolute power corrupts absolutely.