We Need Privacy Now

Does the Fourth Amendment apply to our medical data?

The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no warrants shall issue, but upon probable cause, supported by oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.

According to a report by Milt Freudenheim in the New York Times (And you thought a Prescription Was Private, August 9, 2009), it sure doesn’t look like it.

More than two years ago (Patient Information: Who’s Your Daddy) I warned that for-profit entities might use private patient data to market products to consumers.

Patient data may be used to target relevant product ads to individuals based upon the data contained in the medical record.

Today, patient information is actively being used to target market products and services to patients. Large pharmacy chains such as CVS Caremark and Walgreens regularly utilize pharmacy information to identify patients to whom they send out email messages, coupons, and flyers. Although the data they utilize is de-identified, they employ reverse lookup utilities to reconstruct the information with patient identifiers.

At a meeting with several health information technology leaders at the HIMSS 2008 Annual Conference, Google’s CEO, Eric Schmidt, was cautioned about the use of patient data contained within Google Health. Although WebMD and Microsoft currently acknowledge the privacy rules outlined in ARRA apply to them, Google disagrees. Freudenheim quoted in his article a representative of Google who said:

Google is bound by the privacy policy that people agree to when they sign up.

WOW. To this day I still have not met anyone who reads those legal notices we all are asked to accept before using software or accessing certain websites. To rely on the acceptance of the privacy policy upon sign up as a defense for using patient information in any commercial way deemed appropriate seems weak and suggests exploitation.

Excerpts from: – We Need Privacy Now – PSQH, September/Ocotober, 2009

Photo Courtesy of  Don Guerwitz Photography – Surprised! Stonetown, Zanzibar, Tanzania.

HIT Alone Not the Solution

In 1980 a Stanford University School of Business professor Alain Enthoven authored a book titled Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care. Dr. Enthoven provided the theoretical underpinnings of managed competition, an approach to reducing healthcare costs embraced by the Clinton administration’s Task Force on National Health Care Reform. Chaired by the then first lady Hillary Rodham Clinton, the task force failed to convince Congress to pass comprehensive healthcare reform legislation. This unsuccessful “breakthrough solution” was just one of many proposed over the last 30 years to save our healthcare system from collapse.

On the first page of Enthoven’s book he wrote about the strain healthcare costs were putting on federal, state and local governments. He then addressed the private sector, particularly the automobile industry, where soaring health insurance costs were a difficult burden on employers. According to Enthoven, healthcare costs made up 6.2% of GDP in 1965 and ballooned to 9.1% in 1978. (1) Today, healthcare costs eat up over 16% of GDP. In the 27 years since Enthoven published his book the United States has seen little progress in controlling healthcare expenditures.

Although our healthcare system struggles with access, covering the uninsured, and medical errors, generally Americans receive pretty good healthcare, especially when their illness is not routine. Unfortunately, the resources currently required to provide that level of care are beginning to impact our standard of living and competitiveness in the world.

Unequivocally, healthcare information technology alone cannot solve the problems our nation faces in delivering high quality, affordable healthcare to all Americans.

A comprehensive approach to healthcare reform is necessary. Everyone, including physicians, nurses, patients, administrators, and insurers must work together to form the solution. Continuing to approach illness and deliver care the same way we have been doing for decades is sure folly.

Physicians and nurses must begin to see their responsibilities in a different light and begin to do their tasks differently. Administrators and insurers must assist and incent them. Patients must take responsibility for their care and work to prevent illness rather than wait passively for resource intense medical miracles to fix them.

Therapies need to be driven by science and rational thinking rather than habit and personal preference.

Healthcare information technology can provide some critical tools to achieve this necessary change, but those working within the healthcare system must employ these tools in different workflows and processes. Utilizing the tools to “automate” existing processes only works to continue delivering unacceptable outcomes.

If we want to truly address our problem of spiraling healthcare costs, it is time to get to work fostering the change management necessary to reform our healthcare system for the better. Otherwise, we will read Enthoven’s book a decade hence and realize nothing has changed except for the slogan.

Source: Healthcare IT: Slogan or Solution? – PSQH, January/February, 2008

Savings from Effectiveness Research Can Fund Reform

The American Reinvestment and Recovery Act 2009 (ARRA) earmarks more than $800 million toward research on comparative effectiveness of medical treatments. In addition, more than $700 million is directed to the Agency for Healthcare Research and Quality, a research institution with a long history of evaluating effectiveness of treatments. With healthcare reform at the top of the agenda for the 111^th Congress and the Obama administration, will a NICE-like entity be part of the reform package?

NICE, the National Institute for Health and Clinical Excellence, makes recommendations on how care, treatments, and medications are distributed through the United Kingdom’s National Health Service (NHS). More than 95% of the healthcare provided in Britain is through the NHS. Prior to NICE, hospitals made decisions about care based upon financial constraints which led to great disparities in care. NICE’s prior approval of drugs and treatments guarantees that all institutions offer the same care options.

Although the use of cost-benefit analysis to evaluate the appropriateness of medical treatments n the United States may seem unique, the state of Oregon first used such an approach more than 15 years ago. The plan’s administrators assembled research panels that reviewed hundreds of treatments, ranked them by benefit and cost, and produced an overall ranking of the treatments for which Medicaid should pay. Estimating the expected demand for each treatment, the administrators then applied the Medicaid budget to the costs of the treatments as ranked, thereby producing a list of approved treatments:

[Budget – (Treatment 1 Cost * Estimated Frequency) – (Treatment 2 Cost * Estimated Frequency) – etc.]

The rejected treatments were those ranked where the budgeted Medicaid funds ran out. Since the list was developed from both cost-benefit analysis and budgeted amounts, many critics of the plan claimed it to be care rationing. Similar cries of foul currently exist in Britain.

Much of the resistance to healthcare reform in Congress and beyond is based on cost concerns. Even though the United States spends more than 30% more per capita on healthcare than any other country, healthcare policymakers struggle to find the sources of revenue to enact reform. The ARRA offers a large sum of money to research the same issues currently investigated by NICE. Perhaps the success of healthcare reform is dependent upon the ability of comparative effectiveness research to show the way to cost savings that can fund the reform.

How the Obama administration intends to apply comparative effectiveness research in future forms of healthcare delivery is unknown. Nevertheless, considering the large investment in this area, it makes sense that at some point it will be offered up as a source of revenue to pay for healthcare reform. This is the only way we can expand access and improve quality without bankrupting our economy and destroying American businesses.

Source: Is It Time to Play NICE? – PSQH, May/June, 2009