Could Doctors Go the Way of Record Companies?

Those of us who follow health care may be overlooking the big picture. Most of the profound (and sometimes disruptive) changes of the last half century – computers, the Internet, social networks – weren’t initiated by the political process. They arose at the intersection of technology, economics, and mass social change. So here’s something to think about:

Could the medical profession go the way of the record industry?

Consider the path that led to the current crisis in the music business:

1. An industry with a near-total monopoly experiences a minor disruption (in music’s case, with the invention of cassette tape recording).
2. It ‘relaxes’ and assumes the crisis has past.
3. An even better technology comes along (the Internet) that includes lateral as well as vertical connections. (Individuals could only make tapes for themselves; sharing was possible but cumbersome, until the Net and mp3s made it instantaneous and worldwide.)
4. The industry fails to recognize the long-term significance and risks of this new tech.
5. Enterprising individuals use this new technology to distribute “information” of mutual interest – songs – through “P2P” (peer-to-peer) file sharing.

The result? A massive and ongoing implosion of the music biz. (David Byrne provided an excellent overview in Wired, with some corrections on his blog.)

Could the same thing happen to the medical profession? Many people’s immediate reaction will be to say ‘no.’ They’ll list the many barriers to what we might call a ‘P2PMed’ disruption of our medical economy (with ‘P2P’ here meaning either ‘peer-to-peer’ or ‘patient to patient’.) Doctors are too respected. Regulations won’t permit it. Doctors control access to medications. Medical information is walled off behind expensive, subscription-only medical journals. It’s unthinkable.

That’s pretty much how the record industry reacted in the 1990s. Let’s look at those objections:

160 million people looked up medical information on the Internet circa 2007, according to Harris polling data. Yet they still go to doctors. That’s true – just as millions of people made tape copies of music for decades without seriously undermining musical economics.

Each of these searches was a solitary activity. The difference will come when a new technology allows lateral information-sharing in a way that people trust. It hasn’t happened yet, but smart people are banking on the idea that it will soon. I agree with that assessment, although none of the many projects I’ve looked at so far struck me as a breakthrough. But a lot of folks are working on it.

Doctors monopolize access to medications through the power of the prescription pad. That monopoly’s already eroding as online pharmacies provide low-cost ‘doctor consults,’ a legal work-around that allows – to an sometimes disturbing extent – easy access to meds. Where there is demand, there will be suppliers.

People won’t spend money based on self-referral. The multi-billion dollar complementary medicine industry demonstrates this is untrue. Most “CAM” (complementary and alternative medicine) transactions are based on self-referral out of the traditional MD/patient relationship.

Medical information is walled off. True, but a backlash against the sequestering of research data is already underway. Case in point: A new publication called The Journal of Participatory Medicine hopes to provide peer-reviewed articles on self care for patients, as board member Kevin Kelly writes.

The Journal’s Advisory Board reads like a Who’s Who of Internet and medical business pioneers (and it’s an open-source publication, meaning its content will be free to all). The Journal goal of helping patients take “responsibility for their own health and healing” (in Kevin Kelly’s words) aligns with decades of movement toward a more patient-centric model championed by both the Left (as “patient’s rights”) and the Right (as with high-deductible “consumer-directed health plans”).

Once again, the left/right paradigm is ill-suited for new developments … and don’t blame initiatives like the Journal if medicine goes the way of record labels. They’re symptoms of broader socio-informational change, not its cause.

We can only guess what such change would look like: A widely trusted P2PMed platform catches fire, followed by widespread adoption of a model we might call “self-directed care.” People use online resources (best practices guidelines, diagnostic tools, etc.) to choose their own care path, then find direct or indirect ways to access the care they’ve chosen.

Not all doctors would go out of business after such a transition, of course. They’re still selling some CDs, too. So who would be most likely to thrive after the transformation?

High-touch practitioners: Empathetic, comforting, and warm doctors.
“Mechanics”: The most gifted and accomplished surgeons sometimes use this word to describe themselves. We will need talented neurosurgeons, cardiac surgeons, and other “fixers” for the foreseeable future (at least until the self-programmable nanobots take over).
Innovators: Doctors who are always exploring, changing, and trying new things, staying one step ahead of the curve.
Integrators: Doctors who can bring together seemingly unrelated ideas and solutions, whether in diagnosis or in treatment. Integration is the foundation of creativity, and creative doctors will always be valued.

Who’ll fail? Doctors who function by rote, who make routine diagnoses, and who connect patients to other resources based on past relationships and not need. Anyone whose expertise and connections are easily replicated on the Internet (think “travel agents”) will struggle to survive.

Watching the AMA defend its turf on issues like doctor reimbursement is like watching the RIAA file copyright lawsuits against teenagers, even as its business model collapses around it. You can’t fight your own market and win, and you can’t fight yesterday’s battles. Doctor groups should look more like think tanks and less like a lobbying groups. (Come to think of it, so should the RIAA.)

A topic this complex can’t be properly covered in a piece this short. And predicting this kind of change is not the same thing as endorsing it. But, like it or not, we should be talking about it now.

Because – like it or not – it, or something like it, is coming.

Health Noir: $10 Million Ransom Demand for Data – and Stranger Crimes Are Coming

(originally written for The Huffington Post)

“Attention, Virginia!” the ransom note begins. “I have your shit! In *my* possession, right now, are 8,257,378 patient records and a total of 35,548,087 prescriptions. Also, I made an encrypted backup and deleted the original. Unfortunately for Virginia, their backups seem to have gone missing, too. Uhoh 😦 ”

“For $10 million, I will gladly send along the password. You have 7 days to decide.”

Someone says they’ve stolen 8.3 million patient records, and now the FBI is on the case. However strange this crime may sound, it was a predictable event. Stranger and more severe crimes are coming, if they’re not here already. I’ve been tracking health data breaches for a while, and it’s one of six scenarios I sketched out (but chose not to publish). It’s important now to ensure that these concerns are given a high enough priority – and proper funding – in future health IT initiatives.

Whatever your position on health reform, nobody wants health data to be the topic of the next private eye novel or film noir. Philip Marlowe wouldn’t be happy working at HHS.

Since they’re now playing out in public, I’ll briefly mention those other five scenarios. They are:

1. Individuals are blackmailed using information obtained from stolen medical records.
2. “Medical identity theft” – using stolen information to fraudulently obtain medical care
3. Stolen information is used to submit fraudulent bills to Medicare, Medicaid, and insurance
4. Electronic funds transfers are intercepted using stolen data
5. Medical data is used to obtain controlled substances and sell pharmaceuticals online

There are no doubt other ideas out there, and inventive minds will find them. Authorities say the Virginia hackers breached the system’s security, but it’s less clear whether they can do what they’ve threatened. Either way, the language in their ransom threat seems to fit the hacker profile of young American kids with time on their hands. We don’t know whether that’s real or a ruse, but it raises a couple of disturbing questions:

– What happens when organized crime gets into the stolen health data business?
– Who says they haven’t already?

Crime syndicates could become brokerages for acquiring and selling health information, which can be traded online.

It would be a mistake to use the threat of these crimes to oppose health IT initiatives, however. These crimes will continue, no matter what, because the exchange of data is embedded in every aspect of our insurance-based health system. Doing nothing will not protect us. It makes more sense to use this historical moment to take bold preventive steps.

If stolen health data fits the pattern of other cybercrimes, publicly reported breaches don’t reflect the full scope of the problem. So what should the Administration and private industry do next?

1. Acknowledge the problem. Don’t lose control of the debate by letting health reform opponents raise the topic first.
2. Provide funding for security software and solutions.
3. Clarify the security levels and procedures expected of all health IT users. (You’d be surprised how many of these breaches occurred because someone left a laptop in an airport or a computer disk on their front seat.)

What should private industry do? Those industries that will benefit from reform and IT initiatives could establish a reward – something like the “X Prize” – for innovative security solutions in healthcare.

Organized crime – or even disorganized crime – has no place in the world of healthcare.

Revolt 2009! Computers Rise Up, Force Improved Health Care Upon Anxious Population

We see Freder descend into the underground city.   There he watches workers frantically push dial hands back and forth.  A valve shows the great machine building up steam. Finally it explodes.  Freder sees the machine transformed into a giant demon, spewing fire and devouring workers.

“Moloch!” he exclaims as columns of workers march into its gaping, fiery mouth.

– Fritz Lang’s “Metropolis,” 1927

From Ezra Klein we learn of the continued use of a discredited story: that Obama created the post of “National Coordinator of Health Information Technology,” presumably for sinister reasons. Improved health IT is actually one of the few issues where left and right – at least the reasonably informed left and right – agree. The position was actually created by President Bush in 2004. Its Republican-appointed prior occupant and his Republican-appointed boss (HHS Secretary Mike Levitt) both did some good work. Better health information is not a partisan issue – or at least it wasn’t until now.

The latest appearance of this folktale – call it “Obama’s Health Big Brother” – comes in a Bloomberg News editorial by Amity Shlaes that compares the current Administration to the best-known works of the Wachowski Brothers. “Barack Obama has dropped us all into The Matrix,” writes Ms. Shlaes. She continues:

In the Obama Era, it seems, we all pick our way through anxious lives that have something to do with software. Like Keanu Reeves’ Neo, we realize hour-to-hour that we are being manipulated by a system that has its own larger plan.

If only we keep a cool head, we tell ourselves, our powers of logic will help us escape the web. But each move we make, even the one that feels independent, takes us deeper into the Matrix …

President Obama’s $634 billion, 10-year health-care plan undoubtedly appeals to would-be Neos out there … As in “The Matrix,” freedom is a mirage … and there’s no escape.

If I tell you that before she’s done she compares Peter Orszag to Agent Smith, you’ll get the general idea. America reads this and wonders: Do I take the blue pill or the red pill?

(Think I’ll take a Tylenol capsule. It’s blue and red.)

Ms. Shlaes has more, like this line: “There was discussion during the campaign of tax breaks for employers for providing health care.” (Actually, employers already have a tax break for providing health care. But let’s not dwell on the details …)

There’s a pattern developing. It’s the outline of a new politically-motivated mythmaking that’s about finding spooky sounds on the organ, then playing them over and over until (they hope) the audience runs screaming from the theater. Why pick on the “national coordinator for health information technology”? Because that pedal might sound scary if it brings up memories of all those computers-are-taking-over movies from the seventies. Because some partisans believe that we all share a general anxiety about everything digital, that we all “pick our way through anxious lives that have something to do with software.’

Picture Julie Christie, cowering from a giant mainframe like she did in “Demon Seed.” Except, instead of impregnating her with a human/machine hybrid, this computer wants to provide information about methodologies for the treatment of orthopedic injuries …

Frightening, isn’t it?

The problem is that, judging from the poll numbers, they’re grinding away at the old pipe organ but nobody’s listening. All of which gives me an idea … how about a piece comparing criticism of health reform to ‘Phantom of the Opera’? I could wring 1,000 words out of that one, easy. Think I’ll pitch it to Bloomberg News.

In the meantime, I look forward to Amity Shlaes’ next piece, in which she warns of the enslavement of humanity that’s sure to come if people don’t stop forwarding that cute video of a dog cleaning your computer screen from the inside.

It’s More Than an Electronic Health Record — Call It a “Health Information Highway”

(cross-posted at The Huffington Post)

The stimulus package includes a great deal of money for healthcare information technology, or health IT. Much of this funding is directed toward “wiring” doctors and hospitals with electronic health records, or EHRs. Why should anyone care, other than health software vendors and other industry insiders?

Here’s why: Because the digitizing of medical records could have a far more profound effect on health — and on our economy — than most people realize. The president said the recovery plan will “invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives.” All that and much more is possible. With a new HHS Secretary and health czar, and a White House health care summit scheduled this week, this is the right time to act.

“Electronic health records” don’t sound like a particularly exciting or innovative idea. But neither did “a network that could quickly reroute digital traffic around failed nodes” in case of military attack, or “dynamic routing protocols to constantly adjust the flow of traffic” between computers. Yet those were the modest original goals of ARPANET — which evolved into the Internet as we know it today.

Paradoxically, computerizing the health system in this country could make it much more humane than it is today. But that calls for a broad vision of health IT as an “information highway” that stores information, looks for problems, and eases the many routine interactions that make up the health system. A well-designed “health highway” would have features like these:

A common set of programming specifications for coding, storing, sharing, and manipulating health information. Just as XML (eXtensible Markup Language) allowed web designers to create sites that interact with one another, a health markup language or “HML” could allow systems used by doctors, hospitals, patients, and others to easily “talk” with one another.

The ability for systems to “look for” adverse medical reactions together. Certain harmless drugs become deadly in combination with other drugs, or when a person has other medical conditions. One way this technology could be used is to automatically look for these interactions every time a prescription is electronically “written.”

Personal convenience. A doctor recommended minor surgery for me last week. What if her office had been able to schedule an appointment for me on the spot, send me a before-and-after personal care plan (tailored to my medical history), pre-authorized the treatment — and checked my health plan to tell me how much it was going to cost me?

More privacy than we have today. I began tracking health privacy breaches a couple of years ago, but had to stop — because they’re too frequent. Laptops get stolen with medical information on them, storage disks get misplaced, or computers get hacked. (I wrote a paper about potential criminal uses of stolen medical data, but decided not to publish it …) A comprehensive health IT system would include better protections for health data.

Tools for primary care doctors to manage your health. US and Canadian primary care doctors – the ones who should be managing your overall health — have historically lagged behind their European counterparts in some vital IT capabilities. Health reform depends on stronger primary care – and health IT can help.

Automatic claim submission. Why shouldn’t the health IT network automatically submit my claim after I’ve received medical treatment? Why shouldn’t it tell me how far I’ve gone in meeting my deductible, and share any other financial information I might need? Our current system is too clerical, too bureaucratic, and too difficult to navigate.

For that matter, why should I have to fill out the same forms over and over — not only each time I see a new doctor, but when I fill out multiple forms in the same doctor’s office? This is a pet peeve of mine. And after I’ve had to write down my birthday four times during one doctor’s office visit — then I need to tell them my age, too! (I want to ask, if I just gave you my birthday can’t you figure out how old I am? Well, a computer can …)

The government can’t create systems to do all these things, even with the dollars that have been budgeted. But that shouldn’t be necessary. A comprehensive strategy should lay the foundation for a boom in private initiatives. If the Internet’s any example, people will meet these needs… and hundreds of others nobody’s thought of yet. That won’t just help us save money and improve healthcare. It could also create a new mini-boom in the technology and service sectors of our $2 trillion health economy.

And that sounds a lot like a stimulus to me.

An “electronic health record” may sound dull. Software based on paper-based objects seem inert. But that’s what Facebook was originally — an electronic version of the “facebooks” given to new college students so they can get to know one another. Whenever anything is digitized it becomes dynamic, changeable, active. It acquires the ability to interact with other things. It becomes less like a paper form, and more like a gateway.

Or a highway.

Decoding the Ideology Behind A Health Care Study

Caveat lector.

Healthcare IT News reports (via the California HealthCare Foundation’s iHealthBeat) on a think-tank study that slams the Federal government’s health IT initiatives. That’s odd. Washington’s health IT projects  seem to me to be among their better accomplishments of the last eight years. (Not perfect by a long shot, and too “consumer health” driven, but on the right track.)

We always need to read between the lines. In this cases, phrases like this one from the study’s presenters caught my attention: “… the federal government is woefully incapable of changing or eliminating outdated rules and regulations. So we will be stuck for all time with whatever they come up with today.”

That seemed like pretty harsh language, not to mention a rigid perspective, for a “research study.”  (As opposed to say, a blog post.)  After all, while we’re not shy around here about noting the limits of government capability (and have the nasty comments to prove it), the Internet wouldn’t exist if not for government funding. And we pride ourselves on not injecting political biases into our own research.

So I did a little Googling on the think tank in question, the “Heartland Institute,” and here’s what I found:

Their self-stated mission is to “discover, develop, and promote free-market solutions to social and economic problems.” They believe that “activists use junk science to stampede the public into fearing chemicals in the air, food, and water, and the possible consequences of poorly understood phenomena such as climate change.” They say our environment is so much better now that “air pollution is no longer a significant threat to public health.”

You heard me right.  Childhood asthma’s up 75%, and the Schwarzenegger Administration’s Air Resources Board reports that “over 90 percent of Californians breathe unhealthy levels of one or more air pollutants during some part of the year.”  But for these guys it’s “What Me Worry?”

SourceWatch states that Heartland is closely tied to the tobacco industry, received funding from ExxonMobil, and took in more than $2 million in revenue than it spent in 2005. It has also received funding from a number of far-right foundations, says SourceWatch.

That’s the baggage that the Heartland Institute brings to its study.  But if government’s so hapless when it comes to technology, why do primary care doctors in North America lag behind their counterparts in Europe – you know, the ones who labor under socialist oppression – when it comes to the use of health IT?

The health economy is complex in this country, and it rarely lends itself to black-and-white solutions based on ideology and self-interest. As I was saying, caveat lector – which means let the reader beware.¹

(¹That is, if I remember my Latin correctly, which is hardly a sure thing.)

Long-Term Thinking About Health: Seven Trends That Should Concern Us

This country is in a healthcare crisis today — but we’re not thinking enough about tomorrow either. Here are seven trends to watch, starting with the short-term and ending with what may seem more like science-fiction.

The seven trends are: Doctors leaving the public system, a shortfall in primary care, underutilization of medical treatment, “superbugs,” virtual health care, climate change, and radical self-redesign and enhancement.

1. Doctors Leaving the Public System: Medicare dodged a bullet when Congress stopped a substantial pay cut for physicians this month. But doctors continue to leave the Medicare system – in Texas, in Washington State, in Tennessee, and elsewhere. And many doctors already limit the number of Medicaid patients they accept. Shortages will become more acute as SCHIP and other reforms (hopefully) increase the number of Medicare and Medicaid recipients, and they’ll hit lower-income and minority communities first and hardest.

2. Unavailability of Primary Care Doctors: Primary physicians (internists, family practitioners, gerontologists, etc. ) aren’t paid enough. It’s part of a general tendency to under-compensate for “cognitive services” – thinking, talking, and diagnosis. Doctors are economic actors like the rest of us. So the result of this payment bias is a critical lack of ‘cognitive’ physicians who should be the drivers of the medical process. Instead, young doctors are being lured into high-cost specialties. This increases the use of costly (and sometimes unnecessary procedures), according to studies conducted at Dartmouth and elsewhere.

This shortage is already crippling health reform in Massachusetts. The idea of increasing compensation for primary care keeps circling around in health circles, as it is now – along with the concept of a”medical home,” which is a re-articulation of health reform ideas that appear at regular intervals like comets. The thinking is probably correct, but the problem will persist – until there is fundamental reform in the way doctors are educated, compensated, and rewarded with social status. And meaningful reform will be difficult without adequate primary care.

3. Underutilization: Medical policy types are well-versed in the cost problems and health complications that stem from over-utilization of health services. Over-utilization is a central tenet of the McCain health proposals. But, while it occurs – especially in certain specialties – the reverse problem of underutilization is prevalent and growing.

As insurers and employers shift more and more costs to individuals’ pockets people are seeking less and less treatment, as this California survey (warning: pdf file) demonstrates. 38% of respondents said they avoided seeking medical care – either preventive or curative – because of health costs. That’s up from 34% three years ago, and it’s a problem. Failure to seek needed care increases health costs, adds to individual suffering, and can allow untreated contagious conditions to spread. Which gets us to …

4. Superbugs: A study of MRSA “superbug” infections published last year found a dramatic increase in occurrence among Chicago’s urban poor. Crowded living conditions in jails and public housing could be a factor, according to the study’s authors, and illegal tattoos may also be contributing to their spread. Now British hospitals are facing a new superbug called “Steno” that is at least as hard to treat as MRSA.

As new viruses mutate and spread, ready access to preventive and curative medicine becomes more critical. Superbugs would be a concern even if we had a fully functional health system. With the system we’ve got, the impact of new mutated viruses could be serious – and potentially catastrophic.

5. Virtual Health Care: Online healthcare holds great promise for the future – both as a way for people to manage their own health, and as a tool that links doctors and patients in a unified network. But even now, before “Health 2.0” is a reality, we’re seeing a wave of health data losses and thefts. (They’ve become so common that I have a whole blog section devoted to privacy issues.)

The combination of electronic medical records, electronic prescriptions, and other online tools could result in new forms of crime – with scary enough potential results that I’d rather not describe them in public. (Why serve as a think tank for the bad guys?) Virtual health could also cause substantial shifts in the kind of medical care people demand. While that might actually be a thing, failure to plan for it could result in some temporary inconveniences.

6. Climate Change: Global warming could change the way we use medical care – and how much we need. As an Australian study found (and we summarized here), overall hospital admissions went up by 7% during heat waves, while mental health admissions went up by the same percentage – and kidney-related admissions increased 17%. That adds up to a snapshot of medical conditions on a globally-warmed planet. Other changes, like a dramatic increase in the occurrence of mosquito-borne diseases, could also take place.

7. Radical self-redesign: ‘Transhumanism’ – the movement to re-engineer the human body – isn’t a well-known term today. But the process is already underway, and it will gain momentum in the coming decades. Choosing our children’s genetic characteristics … building computer technologies into our bodies … extending our lifespans … all of these will come into being in the coming years. This will raise a series of questions in fields like medical ethics and health financing, as we’ve discussed before.

What should we be allowed to do to ourselves and our children? Which changes should be paid for as a social right, and which are a personal choice? Will we create a ‘two-tiered’ race of human beings? These science-fiction questions will become increasingly concrete as we consider the health care reform issues of the coming century.
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(image Creative Commons, courtesy Leo Reynolds)

Stop Thief!

A Harris Interactive poll suggests that public awareness of health privacy concerns is on the rise, according to a report in Modern Healthcare.  The poll is described as an “online interactive” survey, however, which raises concerns about sampling validity.  That caveat aside, it’s interesting to note that there appears to be increasing public awareness of health data theft and data security issues – which, as we have written here before, are rampant.  (We’ve been following health privacy concerns for some time now.)

The poll also suggests that data thefts could be undermining public support for Electronic Health Records (EHR), which is another reason to get this problem under control before it escalates any further.

The Modern Healthcare article also reports that Booz Allen Hamilton was awarded a $450,000 grant in order to

…do an “environmental scan” to get its arms around the problem, then convene a meeting to gather ideas on how medical identity theft should be addressed, and then to write up an action plan recommending ways to deal with the problem.

I would’ve liked to have that contract, and I could’ve done it for a lot less.  We haven’t begun to explore the full implications of rampant health data theft – and we shouldn’t, at least in a public forum.

Still, I suspect the real solution to this problem is going to come from an imaginative entrepreneur, not a Federally-funded study.

(via CHCF’s iHealthBeat; image courtesy Medical Informatics Insider)

Health Information Online: New & Interesting Developments

People keep trying to provide comparative cost information that health “consumers” can use to make their treatment decisions. Many of us have predicted that someone would try to be the Travelocity of health purchasing, and Carol.com says it wants to be exactly that (as reported in the Minneapolis Star Tribune).

I tried the site. It’s ambitious, and in its own way it’s also overtly political. “Competition has changed every market but health care,” the Flash introduction says. “That’s about to change.” Some would argue that there are many reasons why health care can never fit simple market models, including confusion about what exactly is being bought and sold. (Is it “wellness”? A fix for your specific health problem? Or just a set of individual treatments, none of which can be predicted in advance?)

I had some difficulty following the process for acid reflux, the condition I’d selected as a test. It came up with only one “price” of $213, from one provider – but what was it for? Diagnosis? Treatment? End-to-end cure? How much will I need to pay for pharmaceuticals? Will I need to return quarterly? Annually? Ever? If it’s just one office visit, it should say so. If it’s a treatment plan, it should say that.

This is not to knock Carol.com’s creators unfairly. They have an interesting take on this often-discussed idea, and according to the Star Tribune they’ve already affected some unit pricing in the area. And I love their attempt to use decision trees to help people figure out what they need. (Try it – it’s interesting.)

But they need to be cautious about over-promising, and they need to recognize that most of their users will be insured – which will make their pricing information misleading, if not irrelevant. Most of all, they need to define the commodity that’s truly being bought and sold in the health market. That’s the hard part.

Meanwhile, Kaiser Permanente seems to be pioneering an different model for Internet interaction with the health process. iHealthBeat summarizes the features of Kaiser’s new member portal (free registration required), as originally reported in the Sacramento Business Journal. Features include appointment scheduling, prescription refills, viewing lab results, and e-mailing doctors (who will presumably write back).

A staff model HMO like Kaiser is the obvious place to develop a successful service of this kind. All the needed information is present under one roof. Since doctors are employees and not independent businesses, they can take time to answer emails without losing income.

The logical next step is to develop a similar service for the majority of Americans who don’t belong to group or staff model HMOs. That will require some leg work and some cooperation, especially among physicians, laboratories, and other diagnostic providers. And it will require financial incentives for providers to participate, including a payment schedule for answering emails and a system for transferring medical information securely.

(Carol.com, on the other hand, charges providers to participate. That may alter the blend of participants away from the lowest-cost providers, especially on the physician side. And who makes sure data is updated?)

What else will it take to succeed? A thorough knowledge of the inner workings of our so-called health “system,” and a clear-eyed look at the motivation of the participants.

In related news, California is posting a list of hospitals willing to provide discounts to uninsured patients, along with a comparison-shopping tool. Two Michigan health systems are posting their prices for common procedures (but note – these are charges, not the payments they typically receive for these services. Caveat emptor and all that.)

Prediction: Not very many people will use these California or Michigan portals. There will be one or more sites that do become popular someday, but they’ll look like a cross between Carol.com, secure email, and a supercharged search engine.

The goal is to create the classic “knowledge pyramid”: Data needs to be organized into information, and information needs to be organized to become knowledge. If somebody builds it, they will come.

Are ‘Medical Googlers’ Really A Problem?

After dozens of ventures to create health sites for health consumers, most people still seek medical information through Google. That surprises some tech investors. What’s more, the very act of searching ticks off at least one doctor, and probably many more.

Dr. Scott Haig is aggravated by “Susan,” a patient he considers a “medical Googler” (as he writes in TIME Magazine and as covered in the New York Times). ” We had never met,” he begins, “but as we talked on the phone I knew she was Googling me.” Sounds a little defensive to me. That clackety-clack typing sound he heard could have been her making notes on the conversation, or Googling her health condition, or any number of other less personal activities. (Presumably she Googled him before she placed the call.)

It is rude to surf the Net while you’re on the phone – I’ve been busted for it myself. But no need to jump to conclusions.

Dr. Haig goes on to describe Susan’s irritating personality and seemingly inept parenting – as if those two were inevitable and inseparable characteristics of the “medical Googler.” But guess what? Studies indicate more than 130 million Americans sought medical information online last year. Are they all obnoxious jerks?

Dr. Haig’s reaction is indicative of a deeper trend that troubles many doctors: Patients are arming themselves with medical information and making their own decisions. In the abstract, that’s what they should do. But in practice, it results in a shift away from the doctor-centric model – physician as priest – that many practitioners understandably find more comfortable. And there are risks, which technology has been slow to address.

But here’s the bottom line: They’re here, they’re search-engine is near, get used to it.

If Dr. Haig’s description is accurate, Susan sounds like the kind of annoying patient doctors have had to tolerate since the dawn of the profession. Her ‘Googling’ doesn’t make her who she is – and she won’t change.

But physicians like Dr. Haig will have to adapt – or spend the rest of their careers in a state of heightened aggravation. The ‘Medical Googler’ (and her descendents on newer platforms) are the wave of a future that’s already here.

Health Privacy Creates Policy and Technology Challenges

Last summer the Wall Street Journal ran a piece about inaccurate data on medical records, which is a common problem. That led WSJ blogger Jacob Goldstein to observe that, when it comes to obtaining health coverage, medical records are the new “credit score.”

He’s absolutely right – although you can argue that, as reporters say, he “buried the lede.” Most people don’t even realize that insurance companies ever see their personal medical records. That’s a significant story. In fact, most people have no idea who sees their medical information or where it goes. I’m not aware of any comprehensive study on the collection and distribution of medical information.

I do recall seeing a research paper on insurance information in the 1980’s that said that the typical medical bill is handled by 25 different people before it is paid or denied. (No citation available, though I’ve tried to track it down – so consider it apocryphal if you must.)

Policy Need #1: Public awareness, debate, and accountability for the sharing of medical information in the claims administration process.

The digitization of medical information is the new “bipartisan” issue of the 21st Century, uniting politicians from Hillary Clinton and John Edwards to Newt Gingrich. And there are compelling reasons for it, whatever shape health care reform eventually takes. But there are risks.

There have been many security breaches of health data involving hundreds of thousands of patients and their medical records, as we’ve discussed before. (The total number of people involved in any type of data breach over a three-year period? 159 million.)

Technology Need #1: A health security coding system for providers and payers that really works. A number of people are working on it, and there’s a university study group tackling the issue, but nobody’s cracked the code yet in a way that these various markets can embrace.

Then there’s the growing area of health data mining. This can be a very good thing, encouraging both research and better services for individuals. Yet the political state of the art lags behind the technology, which keeps developing. Esther Dyson has an attractive solution: informed consent. Answer those online questionnaires and search for medical information all night if you like, she suggests, but insist that your digital content providers allow you to control what is and isn’t shared.

Policy Need #2: Extend informed consent to health technologies of the future, too, such as telemedicine. It’s an elegant, simple solution to a growing problem – a solution that arose in the private sector. But it doesn’t cover all possibilities. That’s why the American Medical Informatics Association offered some suggested guidelines for the secondary uses of medical data that includes public debate and consensus; a health data taxonomy; and a redirection of the debate away from the ownership of data and toward the the topics of access, use, and control.

We’ll have even bigger problems in the future, including the collection and use of genome data. Dyson understands the implications of genomic information on the insurance industry better than the Economist does, but neither addresses the possibility of genomic data being used for, say, pre-employment examinations.

Would Abraham Lincoln ever have become President if the country knew in advance that he had a tendency toward severe depression? And if he hadn’t been, would the country have been better off?

Technology Need #2: A genomic “reader” that is sophisticated enough to categorize an individual’s enhanced abilities as well as their vulnerability to disease.

Policy Need #3: A national debate on the proper uses of genomic data.

So, when do we begin the public discussion of health data and privacy? And who’s going to meet those tech challenges and reap the economic rewards that will follow?

(Image of secure public health data center licensed under Creative Commons from HMS, Inc.)