Sunday, January 25, 2009

How the other half lives

It's good every once in awhile to rise above the surface of the health care market and see how the real economy does things. Today the Times had an article about the barriers to adoption of near field communication (NFC) technology, which would allow you to swipe your phone over a reader to make credit card transactions. The technology is already in use today in Japan and in the UK, but it's facing many obstacles in the US market.

As described in the article, the issue is not technology. By 2012, most phones are expected to have the technology built-in, yet the availability of the "wave-and-pay" function could take much longer. As an industry expert explained:

For that to happen, all the players will have to work together to define standards, determine revenue-sharing, expand the network of electronic readers and think through the other parts of what he calls "this 2,000-piece puzzle."

The expectation is that a trade association, the NFC Forum, which represents 150 stakeholders in this field, will forge the way to a solution. Yet, the same industry expert warns: is completely possible that nothing will happen in mobile phones in the next five years if everybody keeps thinking only about their own piece of puzzle.

I have no doubt that they're going to figure this out and we'll be waving our phones all over the place relatively soon. Reflecting on the somewhat similar dilemma we face with respect to healthcare IT, I'm struck by two big differences that make health care harder.

First, we'd be lucky if we had only 150 stakeholders. Part of our dilemma in healthcare IT is that the demand- and supply-sides of the industry aren't just fragmented, they're atomized. On the demand-side, there are over 1000 health insurers in the US, and on the supply-side, almost 8,000 hospitals and 170,000 office-based physician practices. HITSP and CCHIT have done a nice job bringing together the technology suppliers (in the latter case, probably too good a job....), but they're only addressing the technical side of this issue. NeHC is supposed to be a forum to forge consensus on market-blocking issues, but they're a top-down creation of the federal government, not the result of the burgeoning demands of underlying grassroots contituencies.

Second, the benefits of health IT aren't as crisp and clear as easier credit card transactions, so our customers (ie, patients) aren't exactly clamboring for what health IT has to offer. Most of us use credit cards very often (all right, probably too often), so little tiny convenience benefits accrue in an obvious way. Most of us don't use the health care system that often, however, so the convenience factor isn't all that meaningful to a lot of us, and so the appeal has to be on less immediate benefits (safety, quality, etc) that are harder to grasp (and believe).

Like the "wave and pay" issue, the obstacle in health care IT is decidedly not the technology. If we can't get "wave and pay" into the market by 2012, what hope do we have of achieving the President's goal of universal EHR adoption by 2014? It's clearly going to take a much larger "forcing function" than the health care market will be able to muster on its own. The Congress' watered down version of the President's health IT vision clearly isn't going to provide that "forcing function", however, so it looks like we're going to have to place our hopes on health care reform.


Phil H said...


I think it's under-acknowledged that a major block to the eHR is the privacy issue. If the legal owner of the data is patient and she doesn't trust the system, how can it function? The proposed solutions I have seen so far are:

1. Use technology to make the system secure
2. disclose data to other stakeholders only with the patient's permission

That last one is flawed. Whenever insurance companies and major providers want access to private data, they ask for and easily get waivers. How can an individual patient refuse? Such a negotiation is not between equal partners... you must sign the waiver or forgo the health care. As a matter of practicality, the patient's legal ownership of her data is a sham. So, savvy consumers conclude that the only way to protect themselves is to not cooperate with a widely accessible and interoperable record system.

I don't know how to fix this, but hopefully recognizing the problem is the first step to a solution.

Written by Micky Tripathi said...

Hi Phil H

It's certainly true that in order to have the insurance company pay your bill, you've got to release the info to them to justify the payment. It's also true that if you want your auto insurance company to pay for damage to your car, you've got to release a lot of info to them as well.

The HIEs that we've sponsored are permission-based, but patients who do not give permission to have their data shared still get the benefit of the EHRs that each physician has in his/her office. Thus, they aren't compelled to opt-in by the threat of not getting treated. However, they also don't get the benefits that health exchange can confer. As long as patients are willing to take that risk, and not hold their physicians responsible for information that was withheld from them, this seems to me to be a workable solution that doesn't compel patients to give their permission against their will.