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You and your commentors seem to place the concerns of doctor freedom above those of better patient outcomes. You seem to claim that we make faster progress without any system for teamwork among specialists serving a single patient than we would with a shared electronic medical record and a focus on outcomes. If that were so, wouldn't we expect to see outcomes in the USA leading those of the other industrialized nations with their national health services? We don't. Instead, we see much worse outcomes at much higher prices.

I agree that if the AMA and other organizations of independent practitioners get to choose, Halvorson's plan is doomed to fail. Still, there is some hope, given the widening recognition of the poor outcomes and very high cost of the way we do health care now, that the payers will enact the kind of reforms that Halvorson has in mind, despite the opposition of wealthy doctors. How do you folks assess the consequences of efforts toward universal coverage in Minnesota and the other US locations where it is being tried?

Do you defend our current practices which support expensive emergency care by cost shifting while neglecting inexpensive prevention and early intervention? Do you defend the virtually complete lack of coordination among specialists serving each patient and the inaccessibility of the patient medical record to both the doctor and the patient? Do you defend the absence of data about outcomes which would permit payers and patients to make sensible choices among treatments and providers?

I do not.

If I misunderstood your positions, then let us choose a systematic argumentation scheme and delve more deeply into this dialog with vigor and persistence.

DickKarpinski@gmail.com

January 1, 2008 9:54 AM

You may be interested to see http://wiki.commerce.net/wiki/Healthcare_3.0_Videos which I found inspiring. It also seems to support Halvorson's thesis while adding the notion of forming cooperative communities of people who happen to suffer from the same illness.

My suspicion is that if a thousand people dealing with their own illness share freely their experiences with and understanding of that one specific disease, they may well come to understand it better than their doctors do. If so, then perhape we can develop another path to advances in medical practices.

January 1, 2008 10:28 AM

Halvorsen's proposals will not encourage cooperation between doctors, nor will they have any major impact on the costs of care. A shared electronic medical record is nice, but by itelf will not impact the quality of care. As long as the current system of paying for healthcare remains intact we will not see major improvements in the care of the general population. If anything, doctors will be forced to answer EVEN MORE OFTEN to bureaucrats about the care they provide, rather than to patients.

January 1, 2008 2:38 PM

janemariemd says "As long as the current system of paying for healthcare remains intact we will not see major improvements...."

But indeed that is what Halvorson says and why he suggests changing it so payers and consumers can see outcomes and so providers can see both the fuller picture of what is happening with this patient and the comparison with how well other providers are achieving good outcomes with similar patients.

Do you say that with convenient access to the rest of the patient's medical record, the providers will ignore it? Won't the threats of the infrastructure vendors, on behalf of the payers, when outcomes are bad because the provider ignored the medical record, cause a change in that behavior?

I think folks who were sharp enough to get through med school can figure out what to do, given the opportunity to get the relevant data.

Now if you are just saying the politicians are too stupid to see the logic, or too weak minded to pursue a sensible plan for universal coverage, I would hesitate to object to your reasoning. Perhaps we do need some smarter, more effective elected officials.

January 1, 2008 4:05 PM

Delete

Perhaps you have read the book; I have not. From Dr. Reece's summary I don't see where it indicates that Halvorson is proposing changing the way healthcare is financed, such that there will not be the monetary incentives for more healthcare, more drugs, more specialty referrals, etc, that exist now. I am pessimistic; I do not believe any major players in this country, be they politicians or the doctor's groups or the AARP, are going to really support and promote this.

I am not suggesting for a minute that providers will ignore a more complete or accessible record. I do think you overestimate the impact of this on patient care. Whether I have easy access to a complete medical record electronically, or have to have the patient sign a release for a paper copy, get it in the mail, and sit down and read it in my spare time (the present state of affairs)--I still have to find the time to look at it, and this effort is not paid for with the current payment system. I would welcome alternative healthcare payment approaches, but I haven't seen any opinion leaders put any forth. Even with a complete, electronic record, doctors will continue to order expensive interventions and tests if they and their patients think their is a chance of the smallest benefit to the patient, and it is in their financial interest to do so. THIS is what needs to be changed.

Finally, I do not believe that crunching of billing data can give us lots more useful info about good and bad outcomes. Many patients have neither a good nor a bad outcome after a healthcare encounter; their health remains the same; but the care may be inappropriate nonetheless. For example, I have a patient who saw a pulmonologist some 15-20 times over several years, and had lung function tests done in the office AT EVERY VISIT, and I don't doubt that there were charges for those tests and visits. But the patient's more pressing problem was evolving dementia, and it was many months before that was finally recognized (and not ever by the pulmonologist). Billing data will not show that this patient had a good or a bad outcome; it just shows the excessive utilization. This patient, by the way, chose to go to the pulmonologist this frequently. Although I am all for giving patients all the info about healthcare they would like, I'm not sure obtaining healthcare is like buying a car or a house. It seemes to be a much more complex endeavor.

January 1, 2008 6:27 PM

Dear janemariemd,

I read the book. Since you care about this and you make a lot of sense, I suggest that you read it as well. I did not believe that such a noble cause would be easy to effect, and I still do not. On the other hand, Halvorson has set up health plans multiple times and done well. His plan is fairly straightforward, and his arguments are convincing to me. I was vastly impressed. I believe that he deals with each objection which you so rightly raise. Indeed the fact that he does so explicitly validates your thoughts about the problems with any such plan.

As we so often say, just RTFM. In this case I firmly believe that you will actually enjoy the experience. Please reveal your conclusions if you do read it.

January 3, 2008 2:24 PM

Dear janemariemd and other commentors,

If you wish, I will order up a copy for you if you promise to read it. You can reimburse me if you like and if you find it worth that expense. If not, please pass it along to someone else or send it to me and I'll reimburse you for that as well.

Have I put my money where my mouth is? (Not literally, as that would be unsanitary.)