E-Health: Ushering Doctors Into the Twenty-First Century
posted by Danielle Citron
The stimulus package will devote $20 billion to build the infrastructure of an e-health system, replacing paper records with digital ones that could be cheaply and easily stored and shared. As the New York Times aptly noted on Sunday, protecting the privacy of e-health records is both pressing and daunting. Although upcoming posts will tackle the privacy issue, a threshold discussion concerns the extent to which this proposal will change current practices and health care professionals’ readiness to digitize their work. Health care providers, on the main, are firmly rooted in twentieth-century practices. A recent New England Journal of Medicine survey of 2,700 U.S. doctors revealed that only 4% used “fully functional” e-health records systems and the remaining 96% stored their patient information in paper files. CNN Monday.com reports that only 8% of the nation’s 5,000 hospitals and 17% of its 800,000 physicians use the kind of computerized record-keeping systems that President Obama envisions for the nation. Computerworld offers more optimistic numbers, suggesting that 25% to 35% of the nation’s hospitals use, or are in the process of implementing, computerized order entry and medical record systems capable of sharing patient data among hospitals, doctors, insurance companies, and pharmacies.
Of course, getting doctors computers for their desks won’t do the job. Systems must facilitate safe information sharing. For instance, physicians and hospitals require record-keeping technology and point-of-service technologies, such as notebook tablets for data entry into e-health record systems. Thirty states have made some strides in this direction, introducing or passing legislation that calls for statewide adoption of standardized health IT systems. Massachusetts wants 14,000 private physicians’ offices to adopt e-health records systems by 2012 and its 63 hospitals by 2014. According to the Vice Chairperson of the Massachusetts e-Health Collaborative, the plan will take two to three years and cost $100,000 per physician. Private hospitals have been innovating as well: Duke has created an online medical record site accessible by patients who can share the data with whomever they chose. The CIO for Duke University Health System explains that its portal is akin to “online banking or Expedia account, which pulls information from various sources and displays it to you. You can pay your bills online, schedule appointments online.” Duke uses Google Health and Microsoft Healthvault to permit information sharing beyond its campus.
All of this suggests that health care providers have much work to do, and much money to spend, in transitioning into the e-Health Information Age. Although strong evidence suggests that the downpayment on a digitized health records system is worthwhile, potentially saving the health industry $200 billion to $300 billion a year, we need to spend the money wisely. It would be shameful if we rushed into the project, in much the same way that states acted too quickly to spend the Help America Vote Act funds and ended up buying inaccurate and unsafe electronic voting machines. Let’s be sure not to do the same here.
February 3, 2009 at 10:13 am
Posted in: Architecture, Health Law, Privacy (Medical)
Print This Post
Responses (17)
A.W. - February 3, 2009 at 10:33 am
I don’t know why you and Frank Pasquale take it as an article of faith the electonic records are the way to go. if they were the way to go, being more efficient, then these for-profit companies would have gone that way. Really, do you have some special insight on the subject that people on the front lines do not?
It is almost never correct to deal in absolutes, but i can say it is 99% of the time wrong to assume that the businesses are not themselves striving to operate at peak efficiency and succeeding far more often than some top-down regulator. To be blunt, this kind of thinking is disrespectful and it begs the question: who are you guys to pretend you know more about how to run a business than people who actually, you know, run businesses?
Toward the end of the post you write: “All of this suggests that health care providers have much work to do, and much money to spend, in transitioning into the e-Health Information Age.”
How cavelier of you to argue that we should force these companies to do so, whether they agree with your cost/benefit analysis, or indeed whether your analysis agrees with reality.
A simple practice to avoid saying something ill-informed and to avoid needlessly screwing up an industry is to start by completing this sentence:
We cannot expect market forces to find the most efficient outcome because…
With you and Frank, it has clearly never occured to you that anyone might wonder whether the market can be expected to figure out the best way to store records on its own.
Frank - February 3, 2009 at 12:04 pm
AW, just tell us where to look for market solutions! Bill Frist has praised the VA for its EHR. Doesn’t that suggest that even conservatives want some government intervention here?
A.W. - February 3, 2009 at 1:26 pm
Frank
The market solution is to let the market decide which is the most efficient way to keep those files, electronic or paper.
You assume that electronic is best. i don’t. i prefer to let the ordinary hydrolic pressure of the market select out the companies that are the most efficient. But by this method, all companies will be forced to do it whether it is the best approach.
And really, it might not be, for all the reasons why people generally don’t like electronic books.
Frank - February 3, 2009 at 2:07 pm
From Ezra Klein:
“Pete Stark’s 1992 health reform bill had a provision moving the system to fully electronic records. Calculating the lives that would have saved, not to mention the money it would have saved, is too depressing a task for your faithful blogger to engage in right now. But it makes it hard to argue that in the alternative universe where we moved towards a national health system in the early-90s that we’d have a less efficient and technologically capable health care sector today.”
A.W. - February 3, 2009 at 3:12 pm
Frank
Right, so an academic claims that it would cost less money.
So… why aren’t health care companies doing it already? You don’t think they like profits?
And as far as saving lives, again, you don’t think they care about that? Even assuming you are cynical enough to assume they are so heartless that they value profits more than lives (which is actually a naive position posing as a cynical one), certainly if this saves lives it reduces lawsuits, a very real and crippling cost.
It is always ludicrous for the academics to insist that something is more efficient, and has obviously been more efficient for years, but for some reason the people in the real world just can’t see it. Its ludicrous and frankly paternalistic.
Take for example, company A and company B, both medical companies in direct competition. Suppose Mr. Klein makes his pitch to both companies, but only company A accepts and shifts over to electonic records. So then A gets sued less, and operates more efficiently, which means they can either 1) pass those savings unto their patients or 2) keep the money and use it to expand their business. or 3) a little of both. So then over time, doesn’t company A have a competitive advantage that, over time, should help A beat B? of course. And even while individual cases may vary (maybe A has better record-keeping practices, but B has better doctors), in the aggregate, shouldn’t we start to see a pattern where all the companies that use electronic charts out-performing the companies that don’t across the board?
And if that happened, soon all the “Company B’s” in America would soon recognize they had to make this adaptation or die. And thus we see a process akin to natural selection whereas the most efficient survive, where the less efficient companies either die or consciously copy the more efficient companies.
Bluntly, economics 101 tells us we should expect companies to generally be efficient, and it is laughable on its face for someone who just sits on the sidelines and doesn’t actually do the work to say, “gee, I know how to do it better than you.” Of course, there is room for innovation, and sometimes the outsider has a good idea. But if its such a great idea, we can expect the companies to voluntarily adopt it.
The market doesn’t always produce optimum outcomes. the issue of pollution is a good example of this, where what is good for the company might be bad for the rest of us. Most of the time the market doesn’t produce an optimum outcome because there is a conflict between efficiency and morality. But it is hard to imagine a conflict between efficiency and efficiency.
In short, I am saying we should ask the market to do what it is uniquely good at: find the most efficient solution. And all the quotes from all the academics in the world cannot rebut the common-sense question: if it is such a great idea, why isn’t it already being done? With the corollary, that if it isn’t already being done, maybe it isn’t a clearly good idea. And if it isn’t a 100% clearly good idea, then maybe we shouldn’t have it imposed from above by the government, but instead let the market work this one out.
And I don’t know why any serious thinker would see it any other way.
Frank - February 3, 2009 at 3:56 pm
Health insurers aren’t doing it already because they can’t capture all the value from keeping someone healthy–the healthy person could switch insurers any time. The VA, by contrast, saves money overall when it keeps people within it healthy.
As Judge Posner said in one decision, an HMO wants to keep you healthy–but if you do get sick, it’s in its interest that you die as quickly as possible, to avoid having to pay for your care. That’s the business incentive in play. He’s not exactly a bleeding heart liberal.
A.W. - February 3, 2009 at 4:58 pm
Frank
Well, the health care industry is more than just insurers. Indeed the people who create the health care records are not the insurers, but the providers. Those are the people you need to get on board for electronic records and I can say as the attorney for one of those providers, the insurance industry has exerted no pressure on use to keep our files in any particular way except for minimum standards to demonstrate actual care was given. So they want to see time sheets, RN visits, and so forth, but they have no concern at all about how those records are kept.
> As Judge Posner said in one decision, an HMO wants to keep you healthy–but if you do get sick, it’s in its interest that you die as quickly as possible, to avoid having to pay for your care. That’s the business incentive in play. He’s not exactly a bleeding heart liberal.
No, but he is an academic, and unsurprisingly out of touch with the real world.
Companies that accelerate death not only get less repeat customers because the customers themselves die, but then the family of that customer won’t buy their coverage, as does anyone who learns of their behavior including entire companies. You forget that most people get their health insurance through work, and when corporations buy health plans for their employees, they are not too keen on seeing their people get killed. Or for that matter they are not happy when their employees are just plain ill-served. Of course they want to save money, too, but it doesn’t save them money if they have to hire new people and train them, or if their employees are sick all the time. And besides, contrary to what the average academic thinks, corporations are collectives of human beings who (gasp) have a heart. And even if they didn’t, if a company is filled with jerks, guess what? That hurts them in their competition for the best employees, and in the long run that harms everything. I mean who wants to work for a company that doesn’t care if you die? This is the kind of thing where economists pretend to be cynical but are in fact naive. It is naive about how the health care industry or the world in general works to think anyone sees it as in their interest to kill people.
And let’s not forget that when a person dies lawsuits are infinitely more likely to occur whether there is merit to them or not. Death can be the most expensive outcome.
But hey, at least it has occurred to you that maybe it isn’t self-evident that an industry is inefficient. We are making progress.
JP - February 4, 2009 at 10:24 am
A.W.,
From a libertarian, market-oriented perspective, you are wrong. Healthcare is currently nothing like a competitive market. Almost every aspect of purchasing healthcare is affected by agency costs, barriers-to-entry, barriers-to-exit, and (of course) regulation.
In the relevant instance, difficult-to-transfer medical records are a barrier-to-exit. They hamper competition by making harder to change providers.
This would be true even if the provision of healthcare resembled an efficient market. An electronic network for medical information is probably a kind of public good.
A.W. - February 4, 2009 at 10:54 am
JP
You are absolutely wrong on this. Of course regulation has a cost and here I am trying to tamp down on that. But barrier to entry and exit?
Who has trouble getting a doctor when they need one? And as far as transferring to a new one, it is not hard to transfer a paper chart. You walk into the office and say “I want a copy of my chart.” And by law they have to give that to you. What’s so tough about that? you don’t have to have it be electronic to make it transferrable, indeed given that the sick population is always disproportionately elderly, they are probably more comfortable with paper charts.
And that would represent one of the few times that regulation did create a good: giving you the right to your charts. But that is because you can answer the question as to why you worry that the market won’t solve it for itself. But after giving us a right to receive a copy of our charts, there is no good reason to require a company to keep the chart a specific way. And the less regulation the better, less we distort the industry until it is no longer a free market (and indeed, arguably that has already happened).
And for the record, I am not a libertarian. But we should not interfere with markets “just because.” We should have a good reason to expect that the market will not produce an optimum outcome.
JP - February 4, 2009 at 11:29 am
“You walk into the office and say “I want a copy of my chart.” And by law they have to give that to you. What’s so tough about that?”
Well, if you’re sick, and in a different state (or even just a different part of a large city), I can think of a few ways it might be hard.
Also, can you identify anyone from any ideological perspective who thinks the current state of healthcare represents anything like an optimum outcome?
A.W. - February 4, 2009 at 2:20 pm
JP
> Well, if you’re sick, and in a different state
Then you give them a call, write a letter, etc. I mean bluntly, you are asking me about a part of my job, and I can say it really isn’t hard. We do it all the time.
> Also, can you identify anyone from any ideological perspective who thinks the current state of healthcare represents anything like an optimum outcome?
Of course not. It is too tied up in regulations. Which doesn’t exactly invalidate my argument.
JP - February 4, 2009 at 2:42 pm
“Then you give them a call, write a letter, etc. ”
And rely on a government agency (USPS) or government regulated telecom monopoly?!?! To some extent, an electronic medical record network (or standardization to allow utilization of an existing network) is simply a technological upgrade of those kinds of network industries.
A.W. - February 4, 2009 at 2:52 pm
JP
So you want it on the web too? Right, on magic “unhackable” servers. What could go wrong?
> And rely on a government agency (USPS) or government regulated telecom monopoly?!?!
Wow, paranoid much? i don’t think the USPS is going to sieze your medical records or otherwise fail to deliver them as copied.
A.W. - February 4, 2009 at 2:56 pm
JP
By the way, USPS and the telecom, where are they getting their orders from, in your scenario when they evilly prevent you from calling about your records or getting them through the mail?
Are the freemasons involved? How about the saucer people? And how do the Knights Templar and/or illuminati figure into this? I one heard that my medical records were in fact encoded in the famous paintings of the renaissance period. Is there any truth to that?
Humor aside, your comment was so silly you should be embarrassed for yourself.
Meg - February 4, 2009 at 3:04 pm
Hi all- Long time listener, first time caller…
It’s been well documented that careful integration of electronic medical records is most beneficial to not only the patient, but to practitioners within the system who are now able to pull up multiple records at their desks.
It would cost less money. Period. I don’t think A.W. distinguishes between health care providers (i.e. insurance companies) and practitioners who, as Frank points out, have very different motives.
This is my favorite:
“Who has trouble getting a doctor when they need one? And as far as transferring to a new one, it is not hard to transfer a paper chart. You walk into the office and say “I want a copy of my chart.” And by law they have to give that to you. What’s so tough about that? you don’t have to have it be electronic to make it transferrable, indeed given that the sick population is always disproportionately elderly, they are probably more comfortable with paper charts.”
Who has trouble getting a doctor?! Really?!!? Um….everyone without insurance and/or the money to pay out of pocket. People who use the ER as a primary care facility, and then don’t have the money to pay the bill or pay for prescriptions/follow up care, so they only go if they think they are on death’s doorstep. A.W. is right – it’s not hard to transfer a paper chart…just like it’s not hard to shoot a file to someone via email. And the sick population IS NOT always disproportionally elderly – they are people of all ages but mostly of working age, who are without insurance so they do not receive preventative care, leading to further and longer lasting problems. Why would you assume that an elderly person automatically is more comfortable with a paper chart? You can always “print them a copy” for their personal records. You know what they say about assuming….
I can appreciate that there are several perspectives here: the insurance company (which may not take into consideration those without insurance); the law professor academics; and now mine, the public policy perspective.
A.W. - February 4, 2009 at 4:05 pm
Meg:
> It’s been well documented that careful integration of electronic medical records is most beneficial to not only the patient, but to practitioners within the system who are now able to pull up multiple records at their desks.
So, answer my question. Why aren’t they already doing it?
My suspicion is it is similar to the reason why people don’t read e-books very much.
And, by the way, an insurer is not a provider. It is a provider of money. A provider is the person who puts their hands on the patient. But that is a definitional snit and not terribly important to the conversation. But the point is, when I talk about providers, I am not talking about insurance companies.
> Who has trouble getting a doctor?! Really?!!? Um….everyone without insurance and/or the money to pay out of pocket.
We were talking about it in terms of “entry barriers.” And bluntly so long as America is not a socialist country, that is just going to be how it is, and bluntly electronic records is not going to change that fact.
And as you mention, even if you can’t afford it, you can still find a doctor.
> A.W. is right – it’s not hard to transfer a paper chart…
Which answers wholly the difficulty of transfer point.
> just like it’s not hard to shoot a file to someone via email.
And with scanning technology as it is, it isn’t hard to take a paper chart and send it to someone’s email without having an “electronic chart.” I have done that myself when the person was receptive to it. most people are not even receptive to that, by the way. They want paper.
> And the sick population IS NOT always disproportionally elderly
Actually, yes they are. You know, frail bodies and all that.
> they are people of all ages but mostly of working age, who are without insurance so they do not receive preventative care
I am sorry, most people don’t have insurance? Or most of the sick? Um, no.
> Why would you assume that an elderly person automatically is more comfortable with a paper chart?
I didn’t. that is why I used the word “probably.”
> I can appreciate that there are several perspectives here
And funny, you leave out the perspective of the health care provider. You know, the people who have to use these supposedly great electronic records and yet for some reason you can’t convince of their superiority.
And all I am saying, Meg, since you seem to be coming in late to this discussion is rather than the government mandate that they be electronic, or not, let the market decide. If electronic records are really better, I see no good reason to think we won’t switch over to them.
Further regulation is inflexible the way the market isn’t. New technology could make electronic records much better or much worse. (how could it be worse? If hackers got better, for instance. or EMT technology was weaponized and given to terrorists.) Markets can react to these changes, but regulations? Not so good.
And while I am not exactly a libertarian as JP thought, I do believe that as a rule less regulation is better, and that we always have to justify regulation by pointing toward a reasoned argument that the market has failed, or should be expected to fail. I really don’t see that argument here.
JP - February 4, 2009 at 4:40 pm
A.W.,
I think I have been foiled by the failure of an internet comment to convey sarcasm. I wasn’t suggesting that there is any problem with the postal service or telephone provider. I was simply wondering why you don’t have any problem with those government subsidized means of communication when you are so adamantly opposed to the very thought of a government subsidized means of communicating electronic medical records. (BTW, your point about privacy comes full circle to a major point of Danielle’s original post.)
Also, I’m aware that you are not a libertarian. To clarify, I am a libertarian, and felt that your “pro-market, anti-regulation” argument was such an unfortunate caricature of a libertarian viewpoint that it required a corrective.
Leave a Reply