Health Care: the Reform Before the Reform

We’re hearing a bunch of different messages about what “health care reform” involves. Obama is now saying it means “health insurance reform,” which many of us have trouble with.  I have a very good auto insurance policy. It neither drives nor maintains my car.  But we all seem pretty clear that we want to cover everybody (or nearly everybody), and that we want to reduce the cost of both health care and health insurance. Whether these various goals are mutually compatible is a whole other question.

But there are things that we can perfectly well do before getting into the details of who is to be covered for what, and perhaps one of the most important is to solve the medical data problem.  Right now, your medical records are paper full of illegible doctor longhand, plus some transcribed and typed notes, plus X-ray films plus images from scans, EEGs, and EKGs.  Depending on your age and state of health, those records may fill a single folder, or, like Mr.Wired’s, be the thickness of the entire New York City phone directory. Furthermore, those records may be taking up space in the office of several different offices and facilities, because Doctor #3 wants to know what Doctors #1 and 2 found when they checked you out for hallux valgus, how they treated it, and whether the treatment worked, before she takes up where they left off. So she has had you send for all of the records from Doctors #1 and 2, and, when necessary, pay for the copying and shipping.  Copying, meaning the originals stay where they started out.  Most health care facilities have at least one room devoted entirely to record storage, sometimes a lot more.

Sometimes, not unreasonably, patients decide they want to keep a set of their own medical records.  This requires another set of copying fees, and another quantum of storage space.  In addition, it requires the patient to find someplace to store X-ray films (which are, essentially, photographic negatives with all their attendant storage problems, and furthermore are roughly four times the size of most paper documents and places to store them.)

BTW, in many other countries (Chile is the one I know best), the medical records are considered the property of the patient, who keeps his/her own set of copies and takes them from doctor to doctor as needed.  I don’t know whether the doctors in question make and store their own set of copies. Considering that doctors do retire, move away, and die, this approach has a lot to recommend it.  Indeed, these days, doctors move around a lot more than they used to, and tracking down one’s records after a few years can be really difficult.

So anyway, creating, maintaining, storing, and transmitting paper medical records is expensive.  Regardless of what happens with the more global aspects of health care reform this year, we could cut medical costs a lot by digitizing the records.  Many practitioners do that now.  My orthopedist puts my X-rays on his computer monitor, where he can zoom in on areas of particular interest and show me utterly cool and fascinating things about them.  He can also email them to anybody who wants them. But his software may or may not be compatible with that of my physical therapist.  That’s where the Reform Before the Reform comes in.
We not only need to digitize medical records, we need a standard system for doing so, so that this information can be readily transmitted to anybody with a bona fide need to see it.  We could, of course, just wait till Microsoft crams their version (which they are undoubtedly working on in some cellar in Seattle) down everybody’s throat.  And in the meantime, health care providers who have committed their resources to some other system will of course be out of luck.  VCR vs Beta, anybody?

Health care is more important than home movies.  It’s important enough for the government to play a role in deciding on a digitization standard.  Presumably the National Institutes of Health would be the place to start.  But obviously the real world of private medicine has to be involved as well.  AMA?  There may be some professional organization of medical IT specialists with contributions to make as well.  Ideally, the private side should be getting together to formulate its standard, which the NIH boffins can then examine for obvious and not-so-obvious glitches.  Mr. Wired suggests that unless the glitches are deal-breakers from the point of view of NIH, their critique should be kept out of the process, or a very minimal amount of tweaking done to produce a workable product.  That product, with recommendations from the private sector and NIH, should then be forwarded to the Surgeon General for his rubber stamp.  Probably the resulting system should be open code and licenseable to everybody who wants it. After a reasonable period of time (5 years or so), all government agencies that deal with individual medical records can legitimately require that they be digitized in the Standard Format, whatever it may be, and then, probably, everybody else will follow suit.

Within ten years, the system will have eliminated at least half the paper storage space (I’m assuming that the original originals will continue to be kept on paper, as a backup), and most of the costs of transmission and copying.  As an additional benefit, that digitized information can be made available almost instantly on demand for emergency responders.

Obviously, such highly personal records will need to be kept under varying levels of security.  One level for emergency responders, another for primary care providers, maybe another level for insurers, and so on.  Which is a lot easier to do (and where necessary, undo) digitally than on paper.  A person’s entire medical record could be kept on a single memory stick, and the emergency provider portion of it, probably, on a chip the size of the one embedded in my cat’s back to identify her if she goes astray.

No matter what else happens to the health care system over the next decade, this single advance can cut costs and improve care by significant amounts.  I don’t offhand know whether any other country has done this yet.  I know that various providers are doing it locally. The Veterans Administration is working on it.  But universality is more important here than anywhere else.  I welcome comments from the docs here, and anybody else with specialized knowledge to contribute.



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