Centralized Medical Records, Behavioral Modification and Security

The currently debated “stimulus” bill has about $300 million in it for establishment of an electronic medical record system for the government. I mentioned this briefly in a previous post but think it should probably be explored in more depth.

The idea of a central repository for all medical records has great merit in an ideal world. Information would be available, no matter where a patient was located, about past medical history, allergies, current medications, and past surgical history. Since everyone is altruistic and no one would access information that was not required, the system would be wonderful in an ideal world. We don’t live in an ideal world.

A central repository of any information of value is a hackers dream. That information would be so valuable to obtain that it could be sold surreptitiously to potential employers, insurance providers, for personal motives, etc. by anyone with access and enough temptation. Miscreants could erase or modify the records for profit or for malicious reasons. The government would counter with a back up system of records. That just provides a broader target to access the information. Even without hacking through computer safeguards, the records could be compromised by individuals through bribes or other personal motives. This is a relatively common occurrence when it comes to national security issues in the United States. People with agendas or personal political philosophical differences with the government pass information to liberal publications like the Washington Post and New York Times which routinely publish classified information. Even more recently, out of one hundred forty anonymous screening tests for baseball players concerning steroids, only the name of Alex Rodriguez was leaked to the press. Someone clearly had an agenda against Alex Rodriguez. It is easy to see similar leaks for candidates for office, other sports figures, celebrities, and for personal vengeance. A history of a sexually transmitted disease, elective abortion, or potential debilitating disease could be used for extortion or political blackmail.

The breadth of the system is inherently a security and bandwidth problem. In order to be effective, the records will have to be available to any medical facility in order to care for patients wherever they present for care. That means that tens or even hundreds of thousands of facilities will have access to the system. A system that large will be similar to the AHLTA military system which is slow, unwieldy, and crashes regularly. A system with that kind of capability probably doesn’t exist outside of the military or National Security Agency anywhere in the world. An electronic health record system which is undependable would be a danger to patients as necessary patient information would not be available when required. Additionally, with the many thousands of access points to the system, there is no practical way to adequately maintain the security of the system. It is like a fence with thousands and thousands of gates, any one of which when breeched makes the entire system accessible.

As a physician, I am well aware of the tendency of health care administrators to now view patient care as a “product line”. In a group of physicians, I have once actually been instructed by a senior administrator to increase patient throughput even if it increases risk of inadequate diagnosis. The reason I bring this up is that there is a tendency for anyone under a time constraint to avoid “reinventing the wheel”. Errors in records in a central repository will propagate because the information will convey authority and go unchallenged. Errors will be like bad tattoos and go with patients everywhere.

To use the hackneyed Orwellian analogy, all health care information in the hands of the government is not a good idea. I will point out that while the government will be a problem, it may not be the biggest problem. With a records system that will inevitably leak like a sieve, it is only a matter of time before private insurance providers get their hands on the information. With that information in hand, insurance companies will begin to modify their actuarial tables depending on your private information. If they note a minor injury while surfing, skiing, sky diving, playing contact sports, riding, etc. you will have the option of stopping the activity, not being covered while doing it, or paying higher premiums. This type of focus will eventually lead to widespread financial behavioral modification. The analogous government scenario is to force behavior modification by denying benefits for activities, diet, etc. that are not approved by some group of “experts” who decide what they want you to do and not do. This is not a new argument. There was a suggestion years ago that in states with motorcycle helmet laws, if you didn’t wear a helmet, there would be no government funding for your health care should you be injured on a motorcycle. The idea was fairly popular. The same has been suggested for bicycle riding for children and cigarette smoking. The idea being that the government says out of one side of the mouth, “We aren’t forcing anyone to change their behavior” while making the behavior so financially untenable that no sane person would engage in it. It is a slippery slope that eventually leads to only government and insurance approved lifestyles being covered. Anything else leaves you on your own.

One advantage proponents will claim is the ability to gather data about treatment options and outcomes. Former Senator Daschle has already written in his book about using those data to determine which treatments will be available. In other words, the financial behavioral modification will not only be used on patients, it will be used to force physicians to become robotic in their prescribing and treatment patterns. Once again, it will be “Treat the patient in the way you see fit, but we will only pay you if you do it the way we want.” If patients cannot be treated individually, we might as well scrap the entire health care system and have everyone use a site like WebMD to treat everyone. There is no reason to talk to patients and examine them if it isn’t going to make any difference in what you can do for them.

My counter proposal, which I have actually sent to Senators Graham and DeMint, is to not have the government establish an actual computer system but rather to establish national standards for the electronic medical record. The format of the record, type of computer storage file, and transmission protocols could be specified and monitored by the Department of Health and Human Services. In the past, similar standards have been established for radio and television transmission, automobile safety, food safety, air traffic control systems, and other systems. My suggestion is that a commission or committee of overpaid top notch experts to establish standards has miniscule costs compared to establishing and building a huge overpriced ineffective system of computer networks. Additionally, in a free market economy, software developers will come out of the woodwork in droves to develop and market commercial versions of software to make new electronic records and convert existing records. To paraphrase Field of Dreams, “If there is money to be made, they will definitely come”. Having private companies supply the software will create many high-paying jobs and result in substantial tax revenue to the government, instead of costing huge amounts in government payroll. Additional jobs will be created all across the country when people are hired by health care facilities to convert existing records into the standardized electronic format. The government virtually never gets the appropriate value for its contracts, there is no reason to assume that it will on this one. Therefore, in the spirit of the American entrepreneur, to save hundreds of millions of dollars in taxpayer money and to avoid the Orwellian consequences, I believe the system I am proposing is superior to the current thinking.

The Anonymity of the Internet

There is an interesting case I heard about on the news which I am pondering. A model, Liskula Cohen, is suing Google to find out who is responsible for a web site devoted to trashing her photos and personality. It brings up some interesting arguments.

There will, of course be those who argue for the First Amendment right of free speech. Before I partially agree with that point of view, I feel obligated to point out that the right of free speech was intended to be for political speech. It was the view of the founding fathers that to have a functional democracy, the population should be allowed to hear all sides of issues to make informed judgments. In order to have representative votes, the population has to be educated on political debates. I don’t believe they ever intended exotic dancers to run around naked as part of their first amendment rights. Therefore, I believe the First Amendment is critically important to a democracy when interpreted in that light.

That being said, before the internet, when you spoke out or wrote about a subject, any subject, it was easy to recognize who the source of the information was. That recognition allowed the subject of the discussion to respond accordingly to the speaker or writer. The internet has now allowed anyone, anywhere to widely broadcast any information, factual or not, anonymously without directed response and without ever being held accountable for the content. In law, one of the fundamental rights of trials is to be able to face your accuser and present your side of an issue. It is precisely the anonymity of the internet that allows cowards and provocateurs to make slanderous accusations without ever being held responsible.

In order to win a case of libel in court, one must show that the information presented is false, that damage has been done, and most importantly, that there was intentional malice in the presenter’s publication of the information. This is where almost everyone, particularly news organizations, gets out of responsibility for their false information. They just say they never intended to hurt anyone. In fact, for most public figures, it is assumed that lies about them are par for the course. Whether a Vogue model is a public figure can be debated. The question is more about where the anonymity line is drawn. The fact that some coward calls a model a “skank” is not Earth-shattering but the fact that the person cannot be identified means that all restraint is gone. What if the person is publishing classified data or advocating open rebellion? I can already hear people saying, “But that is against the law!” or "It is only an opinion". Slander and libel are also reasons to be held accountable. The only difference is that it is a civil action, not a criminal one. Can someone knowingly publish false facts or intentionally hurtful information on the internet anonymously with impunity?

Let’s take a couple of more examples: Can someone intentionally publish misleading information about drug dosages which leads to many people taking overdoses of a medication? Can someone intentionally publish inaccurate instructions on how to put a product together which cause injuries to the users? Can someone publish instruction on making home-made weapons? Once again, the arguments would be, “These things cause harm to the users”. But one could also argue that trashing a professional model’s reputation could cause her to lose work and therefore harm her financially. She would, of course, have to show that harm in a court case. But the problem in all those scenarios is that the publisher of the information has no responsibility at all if the publisher remains anonymous. If someone published the above mentioned information in print or spoke it in public, the source is easily identified. I believe that the internet is a valuable tool and cannot conceive of not having access to it but it should not be a wall of privacy for every ne’er do well on the planet to hide behind as they perform nefarious deeds. I also believe that Google and all other internet service providers have an obligation as citizens to not assist people in either committing crimes or causing intentional harm. To the person who made the comments, come out of your mother’s basement, step up to the plate and identify yourself. If you can’t take on a ninety five pound model, you are one sad sack of feces.