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We are all getting very familiar with the problems of inefficiencies in modern American medicine. I wrote an article some time ago that focused on the lack of use of emailing between doctors and patients in the U.S.

Medical Records Systems

Medical Records Systems All Need to Talk to Each Other—Michael T. Hertz

“There is an rumor that says that email communications between doctors and patients are illegal. But more important is the way that medical insurance is set up. Doctors cannot get compensation for the time spent communicating with patients outside office visits. These are serious problems that probably require legislation to correct.

The legislation should provide that, notwithstanding any other law, doctors and their staff may communicate with patients by email so long as the patient wants that and understands that there is some risk that health information is not 100% secure over the Internet. The patient just signs a consent form. The legislation should also provide the doctors must be compensated for the time spent communicating with patients in the same way that lawyers do when communicating with clients.”

But there's a second major impediment to using the efficiency of the electronic age, and that is the way that electronic health records are being handled. This is a $9.3 billion industry, dominated by Epic Systems:

“Instead of ushering in a new age of secure and easily accessible medical files, Epic has helped create a fragmented system that leaves doctors unable to trade information across practices or hospitals. That hurts patients who can't be assured that their records—drug allergies, test results, X-rays—will be available to the doctors who need to see them. This is especially important for patients with lengthy and complicated health histories. But it also means we're all missing out on the kind of system-wide savings that President Barack Obama predicted nearly seven years ago, when the federal government poured billions of dollars into digitizing the country's medical records.”

Having a national electronics healthcare records systems is desirable and will ultimately improve healthcare. But it should be truly national.

Why has this happened? The law that established requirements for digital records “didn't prioritize 'interoperability'—the ability to transfer a medical file from one hospital to another. Unless programmers ensure that their system properly integrates with another, a doctor's computer might spit out something akin to emoticons when queried for key test results.” On top of that, the companies that handle the data “were engaging in "information blocking" "to control referrals and enhance their market dominance." In other words, instead of having a truly uniform, united system, we have one that is segmented, so that a patient whose records are under the control of different data companies finds it hard to have it all pieced together for review by the doctors.

The interoperability problem might remind you of other situations in which there is no uniform system. Consider something as ordinary as the operating system on a computer. If you have an Apple, all your programs are different than if you have one that operates on Windows. If you have a Windows computer but buy an Apple, you have to replace all of your programs at a substantial cost. One would think in this day and age the manufacturers of the operating systems could figure out a way to use any program, but they aren't interested in doing that. They make far more money by forcing the consumer to buy new programs, although logically it would make an Apple more popular if it played all Windows programs as well as Apple programs.

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Consider what happened to the railroads in the 19th century. Originally, track gauge was not standard, so trains from one line could not necessarily travel on another company's system:

“In 1886, the southern railroads agreed to coordinate changing gauge on all their tracks. After considerable debate and planning, most of the southern rail network was converted from 5 ft (1,524 mm) gauge to 4 ft 9 in (1,448 mm) gauge, then the standard of the Pennsylvania Railroad, over two remarkable days beginning on Monday, May 31, 1886.

Over a period of 36 hours, tens of thousands of workers pulled the spikes from the west rail of all the broad gauge lines in the South, moved them 3 in (76 mm) east and spiked them back in place. The new gauge was close enough that standard gauge equipment could run on it without problem. By June 1886, all major railroads in North America were using approximately the same gauge. The final conversion to true standard gauge took place gradually as track was maintained. Now, the only broad-gauge rail systems in the United States are some city transit systems.”

This is the sort of cooperation and standardization that our Electronic Health Records system needs. The companies that control the data should be required to standardize access so that it is simple to collect medical data, wherever it is, and read it.

Is there a privacy issue? Of course – but if the patient wants her doctor to access all of her records, then the doctor should have that access without difficulty. Instead, the cost of sharing data among different vendors has prevented doctors at competing practices from swapping patient information. Reportedly, doctors are quitting practice or being forced to join larger ones because of the data requirements imposed by the law. Doctors are penalized under the Medicare system if they do not comply with the electronic records rules.

As usual with any law, there are unintended consequences. Having a national electronics healthcare records systems is desirable and will ultimately improve healthcare. But it should be truly national. If the startup costs are really high and hurt solo practitioners, then their cost should be shared with practitioners in larger practices. In other words, the cost should be apportioned per doctor using the system, not per practice. Otherwise you have the unintended consequence of driving the solo practitioners out of business. If you establish a national data system, you should not be allowing systems operators to “game the system” and place impediments to access to the data in order to enhance their own profit.

Both Bernie Sanders and Hillary Clinton are running campaigns with healthcare components. Issues like the foregoing should be included. As things stand presently, the American healthcare system is a hodgepodge of regulations, private insurance companies, public healthcare (Medicare, Medicaid and Veterans Administration), private data companies, and public and private hospitals and doctors.

In general, I believe that Americans want doctors to have private practices and not be paid directly by the government as employees. But beyond that, the peripheral part of the system (the insurance, data services, and the like) needs to be rendered more uniform and efficient. This can be done, but to do that we need to move beyond Obamacare to something better. Single-payer for insurance and single-provider for electronic data records would go a long way in that direction.


Michael T. Hertz