The answer is the Medicaid expansion.  This is the biggest and most significant expansion of government health care in the last several decades. Traditional Medicaid covers children, pregnant women, and people under the age of 65 with significantly disabling chronic illnesses such as multiple sclerosis. However, under the ACA, up to 20-30 million additional Americans will be able to get government health care coverage without the need for a disability. They only need to be poor. This is a far more significant development than the individual mandate even though the mandate gets all the legal attention. It’s significant as a potential for a funding disaster and there is recent precedent to support this.

In 1994 Tennessee decided to dramatically expand its Medicaid coverage (called TennCare) to include 500,000 people who were previously uninsured either due to poverty or preexisting illnesses. Ultimately up to 1.6 million became enrolled in TennCare  and subsequently the total annual budget for this expansion went from $2.64 billion in 1994 to more than $8.5 billion in 2005 which far exceeds national health care cost inflation over this same time period. With fiscal predictions that TennCare would eventually take up 90% of the state of Tennessee’s entire budget, massive cuts in enrollment and funding were undertaken amid a storm of protests and lawsuits.

The reason TennCare failed was because it provided generous benefits without much in the way of controls or limits on excessive utilization. The original TennCare program was all inclusive. It paid for everything from dental care to mental health and substance abuse treatment, to all prescription medications, to basic outpatient, and preventive care.  Ironically, managed care mechanisms built into the original program soon collapsed due to TennCare’s low reimbursement rates. ERs stopped bothering to get authorization from doctors to see patients during office hours and managed care companies dropped out after losing money.

To be even more specific, the reason TennCare failed was that, like Medicare and traditional Medicaid, TennCare is not an insurance program. It’s a entitlement spending program by virtue of its generous benefits. It provides financial resources to spend on health care needs both big and small. It’s not as if hundreds of thousands of Tennesseans suddenly became seriously ill. But many were provided funding for every health milady. Instead of taking over-the-counter medications for minor conditions such as chronic arthritis or seasonal colds and influenza infections, TennCare beneficiaries could now visit a medical doctor and receive prescriptions whether it made any difference or not.  TennCare became the equivalent of a government subsidized auto insurance policy that paid 90% of the costs of gas, oil, regular maintenance, cleaning, and minor repairs.

The sad but “convenient” truth is that the uninsured are relatively inexpensive.  As I have stated before, contrary to popular belief the uninsured do NOT flood emergency rooms because they can’t get medical care elsewhere. They are their own best managed care system by avoiding expensive health care except for serious conditions. They have what is effectively an unlimited deductible. The biggest problem with an uninsured population is cost shifting. Uninsured people who do get seriously ill and need health care will get it. Federal law prevents hospitals from turning away patients with unstable medical conditions regardless of their ability to pay. Many of these will become eligible for Medicaid otherwise the costs of their care are “shifted” to the rest of us in the form of higher costs and taxes. Even with cost-shifting however, the overall health care costs of the total uninsured population remain relatively low. For example, in 2008, the uninsured spent $30 Billion in out-of-pocket care and $56 Billion in uncompensated care (usually due to serious injury or illness) of which various government programs eventually covered 75%.

Most cost shifting occurs because of serious illnesses; accidents, heart disease, malignancy, or chronic neuromuscular diseases that lead to hospitalization and/or the need for expensive long term care. If the Medicaid expansion were an actual government subsidized and supported insurance program then it would only provide coverage for serious illness and expensive unanticipated health care needs in much the same way that low cost, high deductible private catastrophic health care insurance does. However, like TennCare the ACA has decided to opt for health care egalitarianism and move towards all inclusive care no matter the need . . or the eventual cost. Using the numbers from TennCare as a guide, the Medicaid expansion may cost $105 to almost $160 BILLION per year to fund an additional 20-30 million Medicaid beneficiaries and this is on top of the current annual budget of almost 300 Billion. And keep in mind, this is BILLIONS to pay for the health care costs of people who are relatively healthy. They’re just poor.

What about the individual mandate? The Department of Health and Human Services (HHS) has stated that private insurance plans offered to individuals or through health exchanges must provide coverage of up to ten general categories including prescription medications, mental health and substance use disorder services, wellness care, etc. Once again, this sounds more like forced health care egalitarianism than a realistic insurance package. Though there is nothing in the HHS rules that specifically forbids the offering of high deductible health care plans (aka, catastrophic health care plans), these types of low premium plans may not qualify due to the fact that much of the initial costs will be out of pocket. But if  high deductible plans do qualify to meet the individual mandate requirements then it is plausible that most relatively healthy individuals will rationally choose to purchase these lower cost plans. Regardless, many who would otherwise be able to afford a low cost high deductible plan will be eligible for government subsidies to purchase a more expensive all inclusive plan.

Voltaire knew about bullshit 300 years before the ACA

The benefit of mandated egalitarianism is that the relatively healthy population is forced to purchase a high cost health care plan that they don’t need in order to offset the health care of the small minority who are responsible for the majority of the costs.  This already happens in the private insurance market where healthy individuals and families purchase expensive all inclusive plans when an HSA plan or high deductible plan would suffice.  These high cost plans are expensive in part to cover the costs of the sicker and more expensive members of these plans. The claim that the costs of the uninsured are directly responsible for increased private insurance premiums is dubious at best since – as mentioned above – the vast majority of the health care costs of the uninsured either come out of pocket or are paid by the government. And now that insurers can no longer deny coverage to those with preexisting illnesses, the premiums of all inclusive plans are unlikely to go down any time soon.

Lastly, there is the basic economic effect of inflation whenever large amounts of money are infused into the system. Fundamentally, the ACA is a massive spending law with a few insurance reforms thrown in for good measure and it will infuse hundreds of Billions of dollars per year in additional government spending into the health care and insurance industries. Since our Federal government already spends far more than it takes in, this additional funding will be in the form of deficit spending. Essentially the government will be printing new money backed by foreign loans it has no intention of paying off anytime soon. Whenever there is an artificial infusion of money into a system the prices of  affected goods and services goes up dramatically. This effect is commonly seen in gold rushes or other proliferation of natural resources on local economies. Without any logical or effective mechanisms to control costs or utilization of health care resources, the ACA is setting us up for an even bigger spike in health care costs.

Expanding affordable health care access to all Americans is a very laudable goal. There are logical and rational ways to go about this . . . . and then there is the Affordable Care Act. It assumes that one health care plan fits all. It infuses Billions in funding on relatively healthy populations with the goal of getting as close to universal coverage as possible without stopping to ponder the actual needs of the very people it covers. It has very little in the way of mechanisms to control costs and prevent excessive utilization because it assumes that 100% of all health care needs are legitimate and that beneficiaries are idealistic liberals who will not  abuse any entitlement program as important as health care.

Like Voltare’s famous paradoxical affirmation that the Holy Roman Empire was neither holy, nor Roman, nor an empire, the Affordable Care Act is likely to prove itself to be anything but affordable.

But it is fun and interesting to see how people adhere to certain segments of a two thousand year old document and completely and conveniently ignore other parts . A case in point is Deuteronomy 22:28-29, to wit,

“If a man happens to meet a virgin who is not pledged to be married and rapes her and they are discovered, he shall pay her father fifty shekelsof silver. He must marry the young woman, for he has violated her. He can never divorce her as long as he lives.”

Not only are you unlikely to ever see this biblical verse in numerical form under the eyes of Tim Tebow, but you are unlikely to see the GOP advocating for this biblical law as an inclusion to any state sexual crimes statues.

BUT,

Of course the same literalists will be opposed to a woman’s right to chose and a homosexual couple’s right to be protected by the same civil laws that apply to heterosexual couples based on . . . . . . biblical literalism because the Bible is supposed to be the word of God.

“The word”? It gets very interesting when you analyze the idiosyncrasies that arise in many verses. Deuteronomy 22:28-29 specifically states that a man should marry his rape victim and pay 50 shekels of silver only if they are discovered!

Seriously?

Correct me if I’m wrong but isn’t GOD, by definition, supposed to be all knowing? And if she is, then why include such a qualifying statement to an obvious rape-and-punishment edict? The answer should be that Deuteronomy was originally part of a basic local civil justice code for nomadic desert people from two thousand years ago that should not necessarily apply to modern life.

The next time that someone advocates against civil rights for same sex couples, ask them if they also would require that rapists marry their victims? Obviously only if they were discovered.

(Found per Reddit)

And this makes liberals mad. So mad that they want the investment income of multimillionaires to  be taxed at the same higher rate that many working Americans pay. Fair enough. But this still doesn’t change the fact that millionaires like Mitt and Warren don’t have to lift a finger in order to make millions. Inequality still exists! Perhaps in addition to a higher tax rate, members of the non-working 1% should be forced to perform a set amount of labor, maybe for charity? Mr. Buffett could give out free individual investment advise and Governor Romney could . . . . . do whatever he does.

Why not? After all, many physicians are regularly forced by the Federal government  to perform thousands of dollars per year in non-reimbursed charity care while being specifically prevented from claiming a loss for such care on their taxes. The scam works like this. The Federal government requires (EMTALA) all full service hospitals that accept Medicare and Medicaid to “treat and medically stabilize” any patient who presents to their emergency room regardless of their ability to pay. Because the Federal government has never effectively defined the condition of being “medically stable”,  patients usually undergo the full gambit of tests and treatments as appropriate for their condition regardless of their ability to pay. The cost of this care is often in the range of tens of thousands of dollars per hospitalization and is often beyond the financial ability of a patient who was unable to afford the cost of health care insurance in the first place. Hence, much of the cost of this care goes unpaid.

A business that loses income from a customer’s inability to pay is often able to claim a tax deduction as a business loss. In order to claim this deduction, the business must show that it incurred a net loss from providing services or products without receiving reimbursement.  However, this only applies to business expenses and not individual effort. A hospital based physician who saw and cared for a patient who never paid for these services cannot claim a deduction on his or her taxes because the physician’s business never lost any money. It is the hospital that will be able to claim a deduction on its business taxes since the care received is a service that consumed supplies, a room, and the time and effort of hospital employees who then must be paid.

As a hospital based physician I earn only what I can bill insurances and the occasional uninsured patient who pays out of pocket. In the course of a year I guesstimate that I perform $40 to $90 thousand in uncompensated care for uninsured patients admitted through the ER as required by Federal law. This is not chump change. This represents not only an extensive amount of my time and effort as well as my expertise earned from prolonged and intensive medical training but the legal liability of a doctor patient relationship for which the non-paying patient retains full legal rights to sue me for any reason.

But it’s not charity care that angers me. I would much rather have a “treat first” and worry about the billing later policy and many of these uninsured patients are in dire need of care. What angers me is that fact that I feel “forced” to work for free by the laws of the same Federal government that won’t give me so much as a pat on the ass and a “good job” before taxing the rest of my income at a rate higher than Mitt Romney’s. I’m not lucky enough to be able to earn thousands of dollars from investments while sitting on the toilet reading the Wall Street Journal. Every cent I earn is from actual work.

If the liberals can complain about unequal tax rates for millionaires then I can complain about uncompensated labor forced by the Federal government. It’s time that physicians receive an individual tax break for uncompensated care performed under Federal EMTALA laws.

The glaring contrast was between employees with different education and training background – and incomes. Physicians, advanced nurse practitioners, and certified nurse anesthetists all seemed to have a far lower rate of absenteeism due to illness than those with less education and training. Even the mid level management and department heads had higher rates of sick leave.  Why?

Does it have to do with getting paid for sick leave? Workers with more training and benefits – those in government jobs especially – are more likely to receive paid time off than unskilled workers. What about income?  Are you more likely to come to work if you make more money? The answer is yes but the reasons are complex. High income means more money lost for unpaid absenteeism (health care providers usually do not have PTO benefits) and a sense of obligation to work harder as a return on what they see as a “gift” from their employer (gift-exchange model).

To be more specific, higher paid workers tend to have more education and training which inversely correlates with absenteeism.

Research by Koopmanschap et al. (1993) found that lower educational levels correlate with a higher risk of becoming disabled. A recent study appearing in the BMJ-Open delved even further into this issue by examining the correlation between innate childhood intelligence and the long term risk of becoming disabled with chronic medical problems. The results were dramatic. Of children tested in 1946, almost 50% of those in the bottom quartile of cognitive ability ended up on long term sick leave compared with only 13% of the top quartile performers. These differences decreased over time as social status became less of a barrier to educational opportunities but significant differences remained.

It’s not clear why intelligence and educational levels correlate like this. Contrary to popular belief, it is not necessarily because of unhealthy lifestyle differences among groups of different education levels.  For example, obesity rates do not correlate well with education or income level. I have known plenty of doctors who are overweight and smoke and substance abuse rates among doctors do not appear to be much different than the population at large.

Rather then being a case of more people with lower educational levels making worse lifestyle choices than those with more education and higher incomes, it’s more likely that people of lower socioeconomic status have far less ability to absorb and to rebound from the negative consequences of harmful lifestyle choices than those with higher education levels and/or more financial resources.

And they might be less likely to appreciate the near and long term consequences that poor health choices have on their overall health and ability to work. The frequent absenteeism among employees with lower rates of education and training are likely a harbinger of a higher risk of developing permanent disability and illnesses. There is not any good data on this phenomenon but the risk is certainly there. In the end, it is simply and relatively easier to go on disability than to continue to work at an unskilled and low paying job while in poor health and in chronic pain.

I’m not sure what was supposed to come out of his mouth. “Candidate”? “Proponent”? “Activist”?

Remember when then House majority leader, Representative Dick Armey of Texas referred to openly gay Representative Barney Frank as “Barney Fag” during a TV interview? Dick didn’t mean to say it. The phrase just came out. Obviously this desecration of Representative Frank’s name by turning it into a homophobic slur was commonly and frequently used by many conservative members of Congress and their staff in much the same way many people use derogatory and racial language to describe other groups of people while in private. Maybe Dick started using “Barney Fag” when discussing Mr. Frank so often that it became routine.  And then during the interview, it just . . came out. That’s a more plausible explanation than the statistically improbable likelihood that Dick’s brain randomly switched Mr. Frank’s last name for a derogatory term for homosexual that happened to start with the same last letter as his name.

According to Sigmund Freud, the tendency to inadvertently say things in an inappropriate context (i.e. a Freudian Slip) is caused by thoughts or beliefs from the subconscious that would normally be unacceptable to utter in public or mixed company. These beliefs are usually suppressed and come out at certain times when triggered. An example would be calling a woman by the name of your ex-wife just because she is very similar to her in appearance or mannerisms. But modern cognitive scientists believe (as I do) that these “slips of the tongue” are usually due to common prior and habitual language usage that inadvertently comes out in an inappropriate context, like a speech or interview.

Which raises the disturbing question. What did Santorum intend to say? Other then the obvious choice, there are not too many nouns that start with “nig . . ” and would make any sense when used in the context of the sentence, “the anti-war government . . . . . ” Nightwatchman perhaps? Like Mr. Armey, what are the odds that Mr. Santorum’s brain almost randomly inserted the worst of all possible slurrs to describe the President in the most inappropriate of contexts? Yea, not too likely. And so then one has to face the possibility that whatever was almost uttered is a habitual term used frequently by Mr. Santorum in private.

But maybe not. It’s far from completely certain that our once and future leaders are secretly racist, homophobic, scumbags. At least we don’t like to think so. Maybe the term that Mr. Santorum nearly uttered came from his belief that the President is really a member of the Knights who say “Ni” and as such the President is more concerned with acquiring inexpensive shrubbery in a two level pattern with a path running down the middle then with important things like the economy or comforting victims of Rush Limbaugh. It’s an entirely plausible explanation and I’m going to stick with it.

Is the President of the United States a member of this shrubbery loving sect?

]]> http://rangelmd.com/2012/03/open-mouth-insert-foot/feed/ 0 http://rangelmd.com/2012/03/how-would-a-facebook-medical-records-system-work/ http://rangelmd.com/2012/03/how-would-a-facebook-medical-records-system-work/#comments Mon, 26 Mar 2012 22:10:22 +0000 RangelMD http://rangelmd.com/?p=789 Last time I went over a few reasons why the current electronic medical records (EMR) industry continues to belch out software that is isolationist and proprietary.  Current EMRs don’t communicate with each other or much outside of the facility or health care system that they serve. Vendors and engineers have literally modeled EMRs to be an exact replacement for paper charts without taking advantage of modern technology beyond that of a fancy word processor.  It’s analogous to transportation technology 100 years ago. The first autos looked like carriages without the horses and very early attempts at flight usually involved a mechanism that flapped like a bird or some ridiculous outfit with wings and feathers.  Modern EMR design has advanced very little beyond being a hard drive replacement for the filing cabinet despite the fact that we have the capability to go well beyond the current technology.

So what does this have to do with Facebook? The important thing about Facebook is that it represents what can be done with “cloud computing” on a massive and efficient scale. Cloud computing means removing data from a local computer or data drive and moving it to a centralized location on the internet where it can be universally accessed. I.e. nobody has to go to a special library or coffee shop in order to access Facebook and nobody has Facebook downloaded and running on their home computer. All that one usually needs for cloud computing is a standard computer and an internet connection thus  minimizing up front costs while allowing simple access.

It is my belief that the current isolationist EMR system is too broken to be fixed in order to create a system where every EMR is capable of communicating with every other EMR. Literally thousands of separate software programs would have to undergo major and expensive revisions in order to meet universal communication standards. Even coming up with industry standards for communication between thousands of different systems would be a massive nightmare (and possibly one of the reasons why it was not addressed in The Health Information Technology for Economic and Clinical Health Act (HITECH) Act of 2009). It would be like trying to get everyone on the planet to agree to a common form of communication (besides soccer). It’s a near impossible task that has been tried in the past with almost zero success.

Instead, what is needed is the standardization of a common computer code or database language for the storage and organization of health care information much like HTML is the universal computer language for internet browsers. Once a standard database language is in place then different EMRs essentially become browsers.  Their selling points then become based on how effectively and clearly they present the information to the user plus whatever additional bells and whistles the user prefers.  And since the free flow of medical information should take priority then why not base these new EMRs on the best communication system ever invented; the internet? Freed of their proprietary shackles, it would no longer be important for electronic medical records to be stored in the physical location of any one practice or hospital. Providers would only need a computer (desktop, laptop, tablet, or smart phone) with an internet connection in order to access a patient’s universal chart from . . . . the “cloud”.

However, there should be several key differences between a social network and a universal electronic health records system. Unlike Facebook, a universal electronic health record (U-EHR) should not be centralized nor dependent upon any one company for development and storage in much the same way that HTML is an industry standard and no one company owns it or the internet. So who is going to store these U-EHRs? The short answer is anyone. Any company that has servers that meet industry standards for safety, efficiency, reliability, and security can store these records.  And who pays for this? Any number of business models can be developed. Like Facebook, servers can come with ads. Or different hospitals and providers can contract with different server companies to provide access to the U-EHR database in much the same way that they contract with an ISP to provide internet access.

Wait a minute. If different companies provide storage of U-EHRs then won’t each version of an individual record be different? Again, communication and flexibility are assets of this system. It should be possible for individual records to compare their current state with records on other servers and update itself if it finds a copy that is more current with recent documentation. This would be similar to how different Usenet servers currently update each other as new posts are added to any one server. This should be done behind the scenes and automatically. illogical conflicts between different copies (i.e. the patient being admitted to different hospitals on the same date) would be tagged to allow users to decide what is the correct or more pertinent information.  Ideally, each record would be like a Wikipedia entry with successive users constantly updating the information. Except that, like current EMRs, older entries and records (office visit notes, lab results, hospital admission records, etc.) would be locked after being electronically signed and changes to THOSE records will only be made with an addendum note.

Such a cloud system has the possibility of allowing for “push” technology for updating U-EHRs. Push technology means actively forwarding information to an application without that application having to call for it (pull) such as sending you email without you having to check it. The push in the case of a U-EHR system would actually be from user to server. Once a new document is entered or changed in the U-EHR that change is communicated or pushed to all known EMR servers and copies of the record. Again, this would be done behind the scenes as different servers receive this new information and records check each other for accuracy.

Such a paradigm shift in how we store and retrieve health care information is going to have a lot of people crying heresy. The idea of decentralizing health care information is going to be alien and threatening to many people. Even though many EMRs currently have the capability for remote access to records over the internet from home or office, many providers are going to oppose such a system because they will feel a loss of control over the records of their patients. They will claim that cloud storage and retrieval of records is not secure or reliable. What happens if the server crashes and it loses all my patient’s records? What happens if the system is hacked and all the records are stolen? What happens if my internet connection goes down? All of these are valid concerns but not absolute contraindications to a cloud based electronic medical records system.

There is no reason to believe that medical information stored in a cloud system would be any less secure than a pile of paper charts crammed into the back closet of an office or an obsolete server running an EMR in a poorly ventilated space.  A single theft, fire, flood, or hard drive failure can take down an entire office EMR but a decentralized U-EHR system would be largely impervious to the destruction of any one server in the highly unlikely event that total disaster ever occurred. And the likelihood of losing your internet connection is about as likely as losing your electricity. The few areas of the country that lack reliable internet access will likely match those areas that lack electricity within a few years.

Security is a bigger concern. Placing very sensitive information on the internet makes this information potentially accessible to anyone on the planet with a computer and a connection. Then again, any EMR with an outside connection for remote access is theoretically vulnerable to attack and professional internet storage providers tend to have far more sophisticated security than Dr. So-and-So running his EMR on a Windows Me server under his desk.  I would think that the loss of one’s bank account would be more of a concern than the loss of one’s medical records but this has not stopped millions of Americans from converting to online banking. In my view, the benefits of online health information far exceeds the risks.

The concerns of individual providers however, will pale in comparison to how much resistance to a cloud system will come from the larger health care industry and EMR vendors in particular. In theory, EMR clients accessing cloud based medical records would be far less expensive (if not free) than current EMR systems which can cost tens of thousands for individual practices or tens of millions for hospital based systems. And incompatible older EMRs will have to be completely redone or scrapped. If your giant hospital conglomerate just spent millions on an old style isolationist EMR just to capture some of the bounty earmarked in the HITECH act, there is going to be a lot of complaining.

Sadly, a universal electronic health records system will not work without substantial participation by the vast majority of health care providers, health care facilities, laboratories, pharmacies, and imaging facilities to ensure that the records are accurate and up to date. The Centers for Medicare and Medicaid Services (CMS) has the power to impose mandates (usually unfunded) and can require all providers and facilities that accept Medicare or Medicaid to participate in such a U-EHR system. But they won’t. CMS would rather mess around with pointless and unproven quality initiatives (read: additional pointless paperwork) than do something that has a significant potential to improve health care safety and quality.

What the internet looked like in the '80s and what electronic medical records look like today.

The Internet beta 0.5 version was nothing like it is today.  Back in the ’80s and the early ’90s the most common way to access the outside world was to use a phone modem to dial the number of a remote computer. These primitive servers usually ran DOS based software called a Bulletin Board System (BBS) which allowed users to post messages to each other. For the most part, these servers were isolated and did not communicate directly with each other. If you wanted to connect to a different BBS you literally had to hang up on one and call another one. There were usually no centralized servers that could link and share information among multiple BBSs. This sharing of information among multiple interconnected computers, servers, and networks is essentially what the modern internet is and once the world wide web started to proliferate in the mid to late ’90s the old BBSs became extinct. Facebook is a perfect example of modern Internet use. It’s essentially a vast central database with millions of users who can easily access information using multiple devices, upload and download data in multiple formats (text, links, pictures, video) from multiple sources and all from a single internet connection.

It sounds like Facebook would make a great starting template for a vast interconnected medical records system. But the reality is that the electronic medical record (EMR) industry is still stuck in the era of the BBS.

The similarities between modern EMRs and the BBS system are striking. Like many old Bulletin Board Systems the vast majority of EMR systems do not communicate with each other (nor even the outside world). Not only are they often incapable of communicating with another EMR or computer but even in 2012 most new EMRs don’t even have an option for sharing information with other systems! This is one of the biggest paradoxes and failures of almost all EMRs. Designed for an industry where the sharing of medical information among different facilities and health care providers is critical to the timely, effective, and safe delivery of medical care, the majority of these systems are designed to share information only within the limited confines of the specific facility or health care system that they serve. EMRs are essentially information islands cut off almost completely from direct contact with the rest of the interconnected world.

The system at the hospital where I work is a perfect example of this isolationist mentality.  In its current form, the hospital EMR cannot send or receive information from doctor’s offices, labs, or imaging centers outside of the actual facility. Acquiring old documentation still requires one or more phone calls, several human intermediates, a fax machine (40 year old technology) and open business hours (no luck if after office hours, on weekends, or holidays). Even worse is that the system can’t even communicate with older electronic systems within the same facility and has no capability to input and store faxes or scans in a format such as PDF for internal viewing. This means that we are still stuck with a hybrid EMR-paper chart system that is often more cumbersome and inefficient than using either system alone.

And how did it get to this pathetic point where a guy in rural Brazil can upload a picture of his strange rash to someone in China in real time but I can’t get critical medical information on a patient found unconscious until their doctor’s office opens the next business day? Given all of the concern about online privacy and hacked Facebook accounts you might think that the health care industry is cautiously avoiding systems where private information could be compromised (never mind that there has not been a massive collapse of the credit markets from widespread identity theft and fraud from 100s of million of Facebook users). The motivation of the health care industry in avoiding interconnected medical record systems is not to protect patients but rather, to protect itself.

Specifically, they want to protect themselves from competition. The majority of health care facilities and health care providers still think about medical records the same way they did 100 years ago – as property or proprietary information. A physical medical chart is considered to be the property of the facility or provider who generated the chart even though the patient is considered to be the “owner” of the information contained within the chart. A Paper chart is usually stored at the same facility where it was created and patients often prefer to return to the same facility or provider if for no other reason then because “that’s where my records are.” Changing facilities or providers can often be a problem for patients who must go through the bureaucratic hassles of making a formal request for their records and then having to pick them up and hand-deliver them to a new office or provider. This system is effectively a disincentive for patients who wish to change providers or health care facilities and is, ironically, a barrier to the sharing of information.

Not surprisingly, the electronic version of the medical record system continues this same isolationist mentality. Even though digital information replaces paper folders and charts, electronic records are usually restricted to the system that generated them. Most EMRs are designed to be run on a server or computer that physically exists within the same office or facility and without any direct connection to the outside world. The only way to share information is the old fashioned way – i.e. the electronic record must be printed out and either faxed or hand-delivered to another office or facility. In this way, most EMRs are little more than a hard drive replacing a filing cabinet. But wait, that’s not all. Most EMRs are themselves proprietary software. Most of the expensive systems in particular are not compatible with transferring information to other EMRs without extensive and expensive modifications. If all EMRs could communicate with each other equally then providers would just purchase the cheapest ones thus damaging the finances of the industry. Right?

Wrong. Business is ripe with examples where standardization and compatibility among different products has lead to expanded market size and share even among competitors. The electronics industry is just one example. Another example is the Internet and web browsers. If Internet Explorer were only able to access web sites running Windows server software, then the massive growth and success of the Internet would have been severely blunted. Instead, the industry got together and decided on a common language (HTML) that is usable by any browser. Obviously industry standards can be voluntary or by government mandate. So the question is; why not make all EMRs capable of communicating and sharing information with each other? The Federal government recently had the chance to do so and severely blew it.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided financial incentives for early adopters of electronic health records and even provided definitions of “meaningful use” and what information an EMR should be able to record and store. But the single biggest failure of HITECH was that it did not define standards of compatibility nor even require compatibility among any of the thousands of different electronic medical record systems. Hundreds of millions if not billions of tax dollars will now go towards further entrenchment of the current isolationist proprietary EMR industry.  And this is not good for patients or consumers either. In theory, if all electronic medical records were freely and easily transferable among different providers and facilities, the artificial barriers for patients to changing providers and facilities wound be gone and providers and facilities would have to compete based solely on the quality and efficiency of their services rather then relying on holding medical records hostage in order to generate return business.

However, improved competition among health care providers is not the primary aim of open and efficient transfer of health related information. Accurate and up to date health care records that are easily and universally accessible have the potential to improve the safety, quality, and efficiency of health care delivery. Costs can be decreased by reducing the need for repeat labs and tests. Older patients in particular would benefit from accurate medication lists and lists of prior drug reactions and allergies to reduce the possibility that providers will prescribe medications that could interact with a patient’s other medications or be contraindicated for any one of their medical conditions.  Ensuring that open and free communication of medical information exists between EMRs appears to be beyond the scope of the current records industry. This is something that only the Federal government will be able to do when and if it decides to get serious about modernizing health informatics.

Or claim that I’ve actually seen a Leprechaun (not verifiable).

Opposes a state mandated HPV vaccine (medically critical to the prevention of cervical cancer) for Texas school children because it will lead to more underage sexual activity. Yup, conservatives were furious at Texas Governor Rick Perry for signing the executive order requiring the HPV vaccine that has the potential to save thousands from cervical cancer. Rep. Michele Bachmann (R-Minn.) called it a “government injection” of a “potentially dangerous drug.” And there is no proof that vaccines lead to increased sexual activity in school children.

And, just to make sure they are inconsistent and morally bankrupt, Texas Conservatives . . . . .

Passed a state law mandating an invasive vaginal ultrasound (a non-medically indicated test) for Texas women seeking a legal abortion because it will lead them to cancel the procedure. Yup, not one conservative has yet called this procedure a “government penetration” nor has anyone come up with a rational argument for the mandating of this procedure . . . . other than the obvious: it’s a deterrent to try and shame women into avoiding an abortion even though there is no evidence that this works.

But, not to leave out the other side of the aisle.

The inconsistent Liberal:

Believes that outlawing marijuana drives legitimate business underground, leads to increased criminal activity, and does not deter use. Wants marijuana legalized.

Believes that outlawing corporate campaign contributions won’t lead to increased illegal campaign financing and does reduce special interest influence on the political process. Wants campaign finance reform.

Usually, alprazolam is prescribed as a short term treatment of acute anxiety disorders. It is classified in the US as a controlled substance with significant abuse and addictive potential. It’s popularity may be due in part because it is widely considered to be relatively mild and safe by many patients and their physicians. But, in fact, alprazolam can be much more toxic than even other prescription sedatives.

However, unintentional overdose with alprazolam alone is unusual (it was responsible for less than a quarter of ER visits  for benzodiazepine toxicity in the US for 2008). What is much more common is unintentional overdoses that involve other prescription medication and/or alcohol. It’s unclear why but it may be that patients are unaware of or tend to minimize the risks of combining different controlled medications that could suppress breathing. Or they don’t realize that alcohol can suppress breathing, be difficult to dose (because you are already intoxicated), and have an additive effect when combined with benzodiazepines.

What I want to know is . . . . who is the physician . . . .  being aware of Mrs. Houston’s very well publicized problems with substance abuse, including cocaine and alcohol . . that he or she felt compelled to write her a prescription for alprazolam or other sedatives which she then reportedly filled at a local pharmacy? It would have been understandable if the late Mrs Houston had diverted another person’s medications for her own use or acquired sedatives over the internet or in another country or illegally on the “street” but from all accounts she was actually legally prescribed these medications by an American physician!

Strictly speaking, a history of alcohol or other type of substance abuse is not a legal or medical contraindication to prescribing controlled medications for a medically valid reason. But, there has to be a good degree of due diligence and caution on the part of the prescribing physician in these cases.  Drug testing can be done on potential candidates for therapy with sedatives and a detailed and complete history of the patient’s prior problems with substance about should be performed in order to allow the physician to get the best possible idea of the patient’s tendencies and potential for abuse. Treatments for pain, anxiety, and insomnia should start with non-controlled medications and drugs with the lowest potential for harm and abuse before stepping up to more powerful alternatives. In the very least, small amounts of potentially harmful medications should be prescribed in a “trial” treatment period to be used sparingly and only as a last resort.

But this approach is often an idealistic fantasy when confronted with the reality of real-world medical practice. Patients can be demanding and incredibly impatient and the physician has only 15 minutes (often less) to gather as much information as possible and develop a complex treatment plan. Too frequently this process gets degraded into the best plan for getting the patient in and out of the office in the shortest amount of time and this often includes a month’s supply of the desired medication and a cursory warning of the risks.

But even without these time constraints, the fact that the patient is a major celebrity can have significant and deleterious effects on clinical decision making. This was clearly seen when Dr. Murry felt compelled to discard sound medical judgement when he delivered a powerful anesthetic to Michael Jackson to treat insomnia. Maybe this is what happened in the case of Mrs. Houston? How can you say “no” to a famous patient?  The temptation to give in to the needs of a super-famous client might have been too much for the local MD.

Still . . . . . this justifies nothing.