BLOG on IT/IS in Healthcare & Life Sciences Joerg Schwarz on Healthcare [Health + Care]

The presidential dabate of Senators McCain and Obama covered the topic of health care IT yesterday, so I though it's time for the long overdue continuation of this blog. I reviewed the transscript of yesterday's debate for accurate quotes and comment from the impartial perspective of a healthcare IT professional - this is not a political blog, after all.

Senator Obama, questioned how he would fix healthcare, said "We are going to invest in information technology to eliminate bureaucracy and make the system more efficient." Was he talking about health information exchanges (HIE)? I think so. HIE exchanges have at least the potential to eliminate reduant procedures and improve quality of care by allowing physicians to coordinate care. This is especially important in the context of Senator Obama's next comment: "And we are going to make sure that we manage chronic illnesses, like diabetes and heart disease, that cost a huge amount, but could be prevented. We've got to put more money into preventive care." Disease management and coordination is indeed an important application for HIE, as they allow care coordination and act as a data source for connected PHR, a topic we discussed in this blog many times. Unfortunately, the body of knowledge in medical informatics is full of assertions that these links between HIE exist, but there is little hard evidence. Why?

I think the core problem with HIE is that they are extremely dependent on demand side returns - if HIE don't have a high level of participation, the return and thus value is low. Given that currently only 25% (depending on which study you read that's actually an optimistic approximation) of physicians use electronic medical records (EMR), the probability p to have a doctor with EMR is 0.25. Now, assuming random distribution, and considering the ideal case that every doctor in a region with EMR would be connected, the probability p' to find three pieces of information about a patient would be 0.25 x 0.25 x 0.25 = 0.02. That's a mere 2%. Sorry, that's the rules of probability. Now, once you get to say 80% coverage, p' would be 0.51, 51%. Still not perfect, but much better. Now, I heard at many conferences that up to six doctors are involved in the care of a single Diabetes patient. Once you apply combined probability, chances are infinitesimal to pull all records together unless ALL doctors are online. So realistically, building HIE will only create the value we are all hoping for if coverage is almost universal.

Fortunately, Senator Obama seems to have known this when he said "This will cost some money on the front end, but over the long term this is the only way that not only are we going to make families healthy, but it's also how we're going to save the federal budget, because we can't afford these escalating costs."

Now to Senator McCain. 

Right off the bat he talked about the role of Health IT: "We need to put health care records online. The V.A. does that. That will -- that will reduce costs."

What does he mean by putting health care records online? Could he refer to PHRs? Well, in the context of the V.A. he surely refers to their medical records system, VistA, which is open source, as discussed here many times, and widely considered as being one of the best EMR implementations on the planet. However - the V.A. has an "unfair" advantage. Going back to my previous probability calculation, the V.A. has almost 100% coverage, meaning all V.A. entities are connected and use VistA, so they have a dense, longitudinal medical record. Doing this outside the VA population is difficult - back to our discussion about HIE and curse of combined probability.

Then he really talks about a core topic of PHRs, incentive programs for good life style choices: "we need to have employers reward employees who join health clubs and practice wellness and fitness." We indeed see this as a major opportunity and are actually working on a campaign to provide the right tools to self insured employers, so they can do what Senator McCain suggested. Watch Kumar's blog for more info on this. Right there you will also find more info on a project we're betting on, medical banking. Medical banking is the logical continuation of the policy to empower consumers to direct their health spending based on informed decisions, and combines flexible spending accounts with PHR functionality.

Later in the debate, Obama and McCain quarreled about the cost of health insurance. Senator Obama claimed that "the average policy costs about $12,000". Later, McCain asserted that "The average cost of a health care insurance plan in America today is $5,800."

Who is right? Both. Check the Kaiser Family foundation report on health insurance cost. The average cost for a family is indeed about $12k, while the average cost for an individual is indeed about $5k. Unfortunately, Senator McCain forgot to mention one big advantage of his plan: uninsured or under insured today have to buy health insurance with after tax money, which is pretty unfair compared to the ones who get tax-free insurance benefit from their employer. Kind of a double whammy: first you have the bad fortune of a job without benefits, and adding insult to injury you then have to use after tax money to buy yourself or your family coverage.

But Senator Obama made a good point about under insurance. He reminded us that "The average family is paying an additional $900 a year in higher premiums because of the uninsured", because the public has to pick up cost of emergency room treatments. Again, KFF provides good data on this subject, and solving the problem of un-insurance seems indeed to be a good value proposition. It's questionable if tax incentives really help people at the lower income scale, where tax progression is usually not a top-of-mind issue.

Anyway - conclusion: whoever will be elected President, health IT will play an important role in fixing the issues we face in health care. From my point of view, the team Obama and McCain did a pretty good job covering most of the topics the Sun health care industry team is working on - HIE, PHR, Consumerism. Good job, Senators. Can't we get them both? The problem is certainly big enough....