Medical Information
Rejected by the New England Journal of Medicine
A terrible disconnect exists between academic medicine and the every day business of medical practice. In a rational world the best treatment options would promulgate from an academic center with time for research and the cultivation of excellence. In reality, however, the pragmatism of private medicine defines a standard of care that increasingly accommodates drug companies, administrative decisions, hospitals and insurance. The medical school today often follows the rules more than it leads. What use to be pocket notes from seminars or respected spiral notebook publications from the medical school, now emerge as tomes of preferred treatment, copyrighted, on CD and sold privately at outrageous prices. A total medical information system, state by state, run by the medical schools may be a better way.
Limited communications exist between educators and practitioners. Much of that interface has become commercial in nature, audit, regulation, contract as in HMO, and a trend towards algorithm. Insurance considerations, litigation fears, and financial pressures distort medical education and judgment. Research is distorted by drug interests, a byzantine ICDA diagnostic coding system, and a physician's strategy to realize payment or to protect the patient from exclusion from his or her own insurance plan. There are expensive claims processing programs that effectively streamline a physicians back office but do little for the patient record, the physician's database or an ongoing medical education. Some commercial patient record programs offer greatly improved record keeping with efficiencies, scalability and multiple access. They do not support statistics, education, public health or current treatment preferences, nor are they interactive with the genetics of the individual.
The void is filled by such offerings as Clinical Evidence or Up-To-Date. There is a real risk of such applications and their algorithms falling under the expanded patent and copyright laws and leading to what I consider the undesirable effect of further commercialization of medical practice. How strange it would be to be denied a desirable course of treatment because you as a physician do not subscribe to the licensed protocol for that particular treatment.
A desirable alternative would be for the medical schools to lead in an open source completely integrated patient information system which would meet all the diverse needs, preserve confidentiality and digest data for research, statistics and knowledge.
The changing environment of medical practice has had the unfortunate effect of directing the evolution of the profession in un-chosen and undesirable directions. Fortunately, a cultural-economic revolution brought about by the digital age may change that. We shift from a too successful industrial age to a nascent Information-Digital Age. Precisely because of the extreme success of our industries of the last century, there is much resistance to the structural shifts implicit in the digitization and free flow of information. The medical profession has been an aberration in the industrial period with a tradition of individual competence, reliability and independence, a cottage industry, if you will. Slow to the changes to the modern era, medicine now finds itself embracing the very tenants that the digital age is attempting to cast off. Our tradition of sharing our research and our successful practices with each other and with students have given way to patents, copyright and confidential non-disclosure statements. Seduced by the promise of modern business, medicine embraced incorporation, advertising, insurance and giant franchises. Late to the table, but once the trend was established, medicine shed its traditions and moved with a vengeance enmeshing itself with the waning industrial age giants. Like the recording and motion picture industries defending their cartel and their control of copyright, drug companies fight for their pricing structure with massive advertising. Health insurance companies fight against universal coverage wherein they are excluded from the process. These are the economic tensions that define our time.
Hypocrites defined a practice of sharing medical knowledge with colleges and with students. Today that would be called open source and be identified with the trend towards free information. Unfortunately, medicine is caught up in the waning power of the pharmaceutical and insurance industries. Blinded by the glitter of the genome and the fortunes to be made, medicine is moving towards more copyright, patent and non-disclosure statements. It would be paradoxical to see medicine grasp these monopolistic tools of a past century just as the intellectual world is moving towards open source and a creative commons, which is so much a part of our professional heritage.
An open source collaborative record keeping system, developed and maintained by medical schools in collaboration with their universities might at once collect a database like none other, provide their physicians with current information and at once literally control the medical delivery system. Whoever holds procession of the information system will hold control of the future. Competition among medical schools can only add to the quality of the programs as they evolve. There are so many benefits to a completely integrated information system, that its implementation would far more than pay for itself, in fact, produce a profit center to help underwrite education.
The program has little value if limited to a few clinics and hospitals. The value of the program increases exponentially to all concerned as the distribution becomes predominant and pervasive. The program should be made available to all physicians and clinics free of charge with technical support.
As it stands there is little chance for a state to negotiate with either HICFA or the congress. Given the control of all patient data for the state, however, the negotiating power becomes much greater. Medical issues vary widely state to state. It just makes sense to answer health needs on a state-by-state basis. Public health departments will benefit from the real-time epidemiological data. Again, the population at large within the state will benefit. Legislators can become enthusiastic over results and governors can compare their state to others. State legislators were not good epidemiologists. The medical schools and public health departments were and are. With a single payer formula, presumably the federal government, the medical schools are rationally accountable for outcome. They will have the statistics to support their performance. The state should be well served.
The ICDA diagnostic coding system leaves much to be desired. Anyone using ICDA in primary care soon realizes that it represents multi generations of overlapping terminology and overlapping systems of diagnosis. There is no statistical value to the ICDA as a database because five digit codes are used weather applicable or not in order for the claim to be processed and not rejected. Reimbursement punishes accuracy and rewards distortion in reporting. It should be abandoned altogether or relegated to a secondary proxy list only for the satisfaction of old imbedded insurance systems.
The patient stands to gain the most. Efficient accurate diagnosis, best current treatment, free choice of physician, adequate time with the provider and fair price will please a lot of patients and will be measurable in the outcome of treatment. Many patients seeking alternative health care because of the high price and demoralized health care providers may return to the mainstream of scientific medicine. Outcomes should improve dramatically. Lawsuits should decrease. The general health of the population should improve. Privacy and confidentiality should be safe in the hands of the medical schools. To whom else might be trusted the sensitive statistical data?
Trust is still an issue. Specialty groups will fear a loss of economic power. Insurance companies will wield enormous political and economic power in opposition and hospitals may join them. The economic imperative for physicians, for medical schools, for the state and for the patients may overcome resistance. The competitive advantage of any provider, group or hospital working with such a patient record system is today even more compelling. In order to buy the trust from every provider, hospitals included, it will be necessary to provide the data base software at no cost, with support and a considerable capacity to customize. The value of the program increases only as the distribution becomes universal. It will not matter if some hang back initially. Initially the insurance companies will be involved as well as the government. With time and with proof of concept the others will come along. Ultimately I believe there will be a single payer system. The bureaucracy will give ground slowly. Trust will be the critical issue. If we come to a single payer health delivery system, I would rather trust the medical school to determine, if I did it right and how I should be reimbursed. I do not trust anyone else. It would be nice to see us move away from the residual greed of the industrial age cartels and embrace once more medicine as a science and with a pursuit of excellence.
A terrible disconnect exists between academic medicine and the every day business of medical practice. In a rational world the best treatment options would promulgate from an academic center with time for research and the cultivation of excellence. In reality, however, the pragmatism of private medicine defines a standard of care that increasingly accommodates drug companies, administrative decisions, hospitals and insurance. The medical school today often follows the rules more than it leads. What use to be pocket notes from seminars or respected spiral notebook publications from the medical school, now emerge as tomes of preferred treatment, copyrighted, on CD and sold privately at outrageous prices. A total medical information system, state by state, run by the medical schools may be a better way.
Limited communications exist between educators and practitioners. Much of that interface has become commercial in nature, audit, regulation, contract as in HMO, and a trend towards algorithm. Insurance considerations, litigation fears, and financial pressures distort medical education and judgment. Research is distorted by drug interests, a byzantine ICDA diagnostic coding system, and a physician's strategy to realize payment or to protect the patient from exclusion from his or her own insurance plan. There are expensive claims processing programs that effectively streamline a physicians back office but do little for the patient record, the physician's database or an ongoing medical education. Some commercial patient record programs offer greatly improved record keeping with efficiencies, scalability and multiple access. They do not support statistics, education, public health or current treatment preferences, nor are they interactive with the genetics of the individual.
The void is filled by such offerings as Clinical Evidence or Up-To-Date. There is a real risk of such applications and their algorithms falling under the expanded patent and copyright laws and leading to what I consider the undesirable effect of further commercialization of medical practice. How strange it would be to be denied a desirable course of treatment because you as a physician do not subscribe to the licensed protocol for that particular treatment.
A desirable alternative would be for the medical schools to lead in an open source completely integrated patient information system which would meet all the diverse needs, preserve confidentiality and digest data for research, statistics and knowledge.
The changing environment of medical practice has had the unfortunate effect of directing the evolution of the profession in un-chosen and undesirable directions. Fortunately, a cultural-economic revolution brought about by the digital age may change that. We shift from a too successful industrial age to a nascent Information-Digital Age. Precisely because of the extreme success of our industries of the last century, there is much resistance to the structural shifts implicit in the digitization and free flow of information. The medical profession has been an aberration in the industrial period with a tradition of individual competence, reliability and independence, a cottage industry, if you will. Slow to the changes to the modern era, medicine now finds itself embracing the very tenants that the digital age is attempting to cast off. Our tradition of sharing our research and our successful practices with each other and with students have given way to patents, copyright and confidential non-disclosure statements. Seduced by the promise of modern business, medicine embraced incorporation, advertising, insurance and giant franchises. Late to the table, but once the trend was established, medicine shed its traditions and moved with a vengeance enmeshing itself with the waning industrial age giants. Like the recording and motion picture industries defending their cartel and their control of copyright, drug companies fight for their pricing structure with massive advertising. Health insurance companies fight against universal coverage wherein they are excluded from the process. These are the economic tensions that define our time.
Hypocrites defined a practice of sharing medical knowledge with colleges and with students. Today that would be called open source and be identified with the trend towards free information. Unfortunately, medicine is caught up in the waning power of the pharmaceutical and insurance industries. Blinded by the glitter of the genome and the fortunes to be made, medicine is moving towards more copyright, patent and non-disclosure statements. It would be paradoxical to see medicine grasp these monopolistic tools of a past century just as the intellectual world is moving towards open source and a creative commons, which is so much a part of our professional heritage.
An open source collaborative record keeping system, developed and maintained by medical schools in collaboration with their universities might at once collect a database like none other, provide their physicians with current information and at once literally control the medical delivery system. Whoever holds procession of the information system will hold control of the future. Competition among medical schools can only add to the quality of the programs as they evolve. There are so many benefits to a completely integrated information system, that its implementation would far more than pay for itself, in fact, produce a profit center to help underwrite education.
The program has little value if limited to a few clinics and hospitals. The value of the program increases exponentially to all concerned as the distribution becomes predominant and pervasive. The program should be made available to all physicians and clinics free of charge with technical support.
As it stands there is little chance for a state to negotiate with either HICFA or the congress. Given the control of all patient data for the state, however, the negotiating power becomes much greater. Medical issues vary widely state to state. It just makes sense to answer health needs on a state-by-state basis. Public health departments will benefit from the real-time epidemiological data. Again, the population at large within the state will benefit. Legislators can become enthusiastic over results and governors can compare their state to others. State legislators were not good epidemiologists. The medical schools and public health departments were and are. With a single payer formula, presumably the federal government, the medical schools are rationally accountable for outcome. They will have the statistics to support their performance. The state should be well served.
The ICDA diagnostic coding system leaves much to be desired. Anyone using ICDA in primary care soon realizes that it represents multi generations of overlapping terminology and overlapping systems of diagnosis. There is no statistical value to the ICDA as a database because five digit codes are used weather applicable or not in order for the claim to be processed and not rejected. Reimbursement punishes accuracy and rewards distortion in reporting. It should be abandoned altogether or relegated to a secondary proxy list only for the satisfaction of old imbedded insurance systems.
The patient stands to gain the most. Efficient accurate diagnosis, best current treatment, free choice of physician, adequate time with the provider and fair price will please a lot of patients and will be measurable in the outcome of treatment. Many patients seeking alternative health care because of the high price and demoralized health care providers may return to the mainstream of scientific medicine. Outcomes should improve dramatically. Lawsuits should decrease. The general health of the population should improve. Privacy and confidentiality should be safe in the hands of the medical schools. To whom else might be trusted the sensitive statistical data?
Trust is still an issue. Specialty groups will fear a loss of economic power. Insurance companies will wield enormous political and economic power in opposition and hospitals may join them. The economic imperative for physicians, for medical schools, for the state and for the patients may overcome resistance. The competitive advantage of any provider, group or hospital working with such a patient record system is today even more compelling. In order to buy the trust from every provider, hospitals included, it will be necessary to provide the data base software at no cost, with support and a considerable capacity to customize. The value of the program increases only as the distribution becomes universal. It will not matter if some hang back initially. Initially the insurance companies will be involved as well as the government. With time and with proof of concept the others will come along. Ultimately I believe there will be a single payer system. The bureaucracy will give ground slowly. Trust will be the critical issue. If we come to a single payer health delivery system, I would rather trust the medical school to determine, if I did it right and how I should be reimbursed. I do not trust anyone else. It would be nice to see us move away from the residual greed of the industrial age cartels and embrace once more medicine as a science and with a pursuit of excellence.
posted by Clancy Hughes | 8/10/2004 01:29:00 PM
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