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The Technological Imperative: the increased utilization of advanced technologies by physicians to "do everything possible" to extend the life of the individual prolonging the inevitability of death (slides 5-6)

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The Technological Imperative: the increased utilization of advanced technologies by physicians to "do everything possible" to extend the life of the individual prolonging the inevitability of death (slides 5-6)

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Interoperability: ultimate goal of widespread compatibility of all digital records to exchange health information (slide 8)

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Interoperability: ultimate goal of widespread compatibility of all digital records to exchange health information (slide 8)

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Electronic Health Record (EHR): a shareable, systematized collection of patient and population electronically stored health information in a digital format (slide 10)

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Electronic Health Record (EHR): a shareable, systematized collection of patient and population electronically stored health information in a digital format (slide 10)

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Blockchain: a type of technology that records information in a decentralized way, which makes tampering information difficult or impossible (slides 15-16)

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Blockchain: a type of technology that records information in a decentralized way, which makes tampering information difficult or impossible (slides 15-16)

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From Bioethics Briefings
Download the PDF
Highlights

Health care costs are increasing at an annual rate of 7% a year, which if sustained will bankrupt Medicare in nine years and increase the nation's overall annual health care tab to $4 trillion in 10 years.

These rising costs are an important reason why the number of uninsured has soared, but the cost problem affects everyone.

Unlike the problem of the uninsured, the cost problem has not captured the public imagination.

New or increased use of medical technology contributes 40-50% to annual cost increases, and controlling this technology is the most important factor in reducing them.

Universal care is the only tried and effective way to control costs but will involve a large cultural shift because cutting the use of technology will seem wrong-even immoral-to many.

Our dialogue on health reform needs to move beyond organizational and management schemes to an examination of our fundamental values about life, death, and how we allocate our resources.

Framing the Issue

Almost everyone knows that this country has a scandalously large number of people who lack health insurance, now up to 46 million and growing. That number is vivid and evocative. But it has overshadowed another, more serious issue-that of the steady escalation of health care costs. Largely due to the use of medical technology, those costs are now increasing at an annual rate of 7% a year. The Medicare program as a consequence is projected to go bankrupt in nine years, and overall health care cost to go from its present $2.1 trillion annually to $4 trillion in 10 years.

Those rising costs are an important reason why the number of uninsured keeps going up. Business finds it harder and harder to pay for employee health benefits, and only 61% of employers even provide them now (from a high a decade ago of close to 70%); and the employers who do provide benefits are cutting them and forcing employees to pay more themselves in the form of copayments and deductibles. The 15% who are uninsured are surely faced with both health and financial threats. But the cost problem now threatens everyone else as well, including those using the Medicare and Medicaid programs.

Yet even if most people are now aware of the dangers of cost escalation (and many know it from personal experience), the problem has not gripped the imagination of the public, the presidential candidates, or the media with the force of the uninsured (even though recent public opinion polls indicate it is catching up). There are a number of proposed and detailed schemes for universal care, but nothing comparable for cost control, which is implicitly unpopular. That's because cost control will mean that just about everyone will be forced to give up something and accept a different, more austere kind of health care.

Consider what serious cost control will require: moving from a 7% annual cost growth down to 3%, which is an inflation of health care costs that is no greater than that of the per annum rise in general inflation. That amounts to a cost reduction of $1.5 trillion over the next decade, so that health care costs settle in at $2.5 trillion in a decade. This would represent an enormous and unprecedented drop in annual costs for a health care system that has never since World War II seen anything more than a short, temporary decline from time to time.

There are at bottom only three system-wide ways in the present system to deal with the high cost of health care, each of which would be unpopular. One of them is to sharply raise taxes to pay for government programs such as Medicare, and for private insurance to do the same with the price of premiums. Another is to drastically cut benefits, giving people less care. Still another is to force individuals to pay more out-of-pocket for their care.

Medical Technology: The Main Cost Driver

The feature of cost escalation that should catch our eye most is the role that medical technology plays. Health care economists estimate that 40-50% of annual cost increases can be traced to new technologies or the intensified use of old ones. That makes the control of technology the most important factor in bringing costs down. Ethics comes in at this point because medical technology is highly valued as a beloved feature of American medicine. Patients expect it, doctors are primarily trained to use it, the medical industries make billions of dollars selling it, and the media loves to write about it. The economic and social incentives to develop and diffuse it are powerful, and the disincentives so far weak and almost helpless. Cutting the use of technology will seem wrong-even immoral-to many.

Even among the economists and others who concede technology's central role in the cost problem, there is considerable ambivalence about how to deal with it. Technological innovation is as fundamental a feature of American medicine as it is of our industrial sector. After all, that innovation has given us vaccines, antibiotics, advanced heart disease care, splendid surgical advances, and fine cancer treatments. And many diseases and crippling medical conditions remain that call for yet more innovation. The opposition to imposing controls on costs is politically more intransigent than the opposition to providing universal coverage. In the case of technology, this opposition is deeply rooted in American culture, which has an obsession with health unmatched by any other society. Comparative public opinion surveys in Europe and the United States indicate a much greater belief in the benefits of technology in this country. An astonishing 40% of Americans believe that medical technology can always save their lives; many fewer Europeans share this fantasy. The old joke that Americans believe death is just one more disease to be cured is no longer a joke. No wonder Brookings Institution economist Henry Aaron-who has prominently called attention to all the problems of technology-has nonetheless written that any effort to curb the introduction of new technologies "beyond what is required for safety and efficacy would be sheer madness."

Indeed, Congress-with support of physician groups and the medical industry-killed two federal agencies designed to assess medical technology from a scientific and economic perspective. Ever since the advent of Medicare in 1965 Congress has not allowed that program to take costs into account when determining which technologies and treatments it will cover.

Changing Values and Seeking Solutions

What then can be done about costs? There are a number of ideas available to meet the challenge, few of them rooted in any experience or evidence. The long-time favorite has been that of eliminating waste and inefficiency, which I liken to keeping the dust out of a drafty house located in the middle of a desert. Medical information technology is a more recent candidate, along with increased efforts to advance disease prevention efforts, consumer-directed health care, and disease management programs.

These are all attractive ideas, but they share a common and crippling handicap. In our messy and fragmented mix of public and private health care there is no effective leverage to put in place good but painful ideas. Government might manage to implement some of them, but only after a long and difficult fight. The private sector has never shown much capacity to do so and, with its market philosophy, it would surely resist government's efforts to impose cost control mechanisms.

Universal care is the only tried and effective way to control costs. The European health care systems do so effectively by means of a strong government hand. They use-among other tools-price controls, negotiated physician fees, hospital budgets with limits on expenditures, and stringent policies on the adoption and diffusion of new technologies. The net result is that they keep annual cost increase within the 3-4% range, have better health outcomes than we do, and achieve all of this at significantly less cost. With the exception of the United Kingdom and Italy, there is little rationing and there are no waiting lists for care.

These methods work well but are culturally and politically unacceptable here. For me, that is the fundamental dilemma in trying to think through the problem. Controlling health care costs requires a change in culture, not just in the management of health care. Since many of the effective means of controlling costs will be painful for us because of our bemusement with technology, resistance to change will be formidable. Effective control will force patients to give up treatments they may need, doctors to sacrifice to a considerable extent their ancient tradition of treating patients the way they see fit, and industry to reduce its drive for profit. Hardly anyone will want to do such things. Liberals will oppose it because, though they favor universal health care, they are also children of the Enlightenment, wedded to endless scientific progress and technological innovation. Economic conservatives will oppose it as an interference with market freedom and consumer choice. Social conservatives will see the necessary rationing as a form of social euthanasia, killing off the burdensome in the name of cold-hearted economics.

However, in principle, cost control is a problem that can be solved. Our health care system indeed contains waste and inefficiency, enormous and absurd variation in costs from one geographical region to the next, a great deal of useless or only marginally useful treatment, great possibilities in disease prevention programs, far too few primary care physicians and geriatricians, and far too many specialists. The fact that the European countries can control costs and limit technologies without harming health is a patent rebuke to our way of doing things.

Can we get there from here? There is a huge economic gap to be closed and no less of a cultural gap as well. We have become accustomed to live (and die) with an expensive and disorganized system, one that serves many ends other than health-a system designed for ever-increasing affluence. It builds upon a model of health and of medical progress that is open-ended and infinite in its aspirations. Suffering, aging, and death are enemies to be conquered, at whatever the cost to other social needs.

We need a good dialogue on health care reform, but one that moves beyond organizational and management schemes. They are important but no less so than some deeper matters:

Should death be seen as the greatest evil that medicine should seek to combat, or would a good quality of life within a finite life span be a better goal?

Do the elderly need better access to intensive care units and more high-tech medicine to extend their lives, or better long-term and home care and improved economic and social support?

Does it make any sense that the healthier we get in this country, the more we spend on health care, not less?

Should we be spending three times more of our gross domestic product on health care than on education, when 40 years ago these amounts were about the same?

For me, those are rhetorical questions. But for everyone, questions of this kind are the place to begin any serious discussion about the control of costs and technology-and that discussion merits attention every bit as much as that of the uninsured. It will be harder but even more necessary.
Daniel Callahan, PhD, (1930 - 2019) was cofounder and president emeritus of The Hastings Center.
Daniel Callahan, "Health Care Costs and Medical Technology," in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book for Journalists, Policymakers, and Campaigns, ed. Mary Crowley (Garrison, NY: The Hastings Center, 2008), 79-82.

Resources

Cover the Insured - A project of the Robert Wood Johnson Foundation. Includes news, facts, statistics, and research.

The Institute of Medicine of the National Academies. Includes reports and issue briefs on public health policy matters, including rising health care costs and the problem of the uninsured.

The Centers for Medicare and Medicaid Services. Includes research, statistics, data, educational materials, FAQs, and a newsroom.

The Alliance for Health Reform. Features a sourcebook for journalists, links to dozens of reports, and webcasts of briefings.

Further Reading

Sean Keehan et al., "Health Spending Projections through 2017: The Baby-Boom Generation Is Coming To Medicare," Web exclusive, Health Affairs, February 26, 2008. Available at https://content.healthaffairs.org.

U.S. Congressional Budget Office, Technological Change and the Growth in Health Care Spending, 2008. Report available at www.cbo.gov.

Henry J. Aaron, "Should Public Policy Seek to Control the Growth of Health Care Spending?" Web exclusive, Health Affairs, January 8, 2003. Available at https://content.healthaffairs.org.

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Health Care Costs and Medical Technology

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From Bioethics Briefings Download the PDF Highlights Health care costs are increasing at an annual rate of 7% a year, which if sustained will bankrupt Medicare in nine years and increase the nation's overall annual health care tab to $4 trillion in 10 years.

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The idea of healthcare reform has been part of our national agenda for years, and members of both the legislative and medical communities, along with the general public, agree wholeheartedly that it needs to be addressed. One component of the overinflated burden of healthcare cost comes from antiquated administrative systems that do not allow for efficient and functional record keeping, to the detriment of both individual patient care and overall systems for health management. One of the multiple agendas of the healthcare reform movement is the development of a universal system of electronic medical records (EMR) that would allow access to patient information at every potential venue of care while still providing privacy, security, and autonomy of patient information.

It seems to be universally agreed that a technologically up-to-date system with access and participation mandated throughout the nation would represent a huge step forward in healthcare reform. It was with this in mind that President Bush created the position of National Health Information Technology Coordinator three years ago. However, there are several stumbling blocks that repeatedly hinder these efforts and that must be addressed. Ultimately, one must consider the basic elements of a successful, robust, universal EMR. Those elements include control, funding, security, accessibility, portability, compatibility, integration from multiple sources, and home-data procurement with medical oversight to maintain the system's integrity. Unfortunately, most corporations are far from altruistic and they are looking at ways to expand revenue sources from patients who are, from the corporation's view, consumers. The potential is endless, but care must be used to avoid a multitude of pitfalls.

Control and Money

The main questions that must be resolved in order to successfully implement any national plan for an EMR system concerns control of information and funding to develop and maintain the system. It seems clear that the only entity with the mandate to develop a system at the national level is the federal government. Only Congress has the authority to develop an EMR system that is designated as universal and requires compliance from all healthcare providers. Without a unified system, each provider, whether they be a hospital, an HMO system, or a private practice, will have their own solution and the end result will be similar to the current problem: incompatibility of systems and the inability to share information.

In terms of funding, the most likely contributor is the pharmaceutical industry. Again, it will require an act of Congress to ensure that pharma interests pay, at least partially, for a national EMR system without any undue influence or advertising content. Only government has control and the ability to ban advertising and still require funding through some form of taxation. The constant reorganization of the pharmaceutical industry through mergers, acquisitions, and the emergence of new start-ups creates an enormous logistical problem for implementation of this idea, but the alternative is to require the general public (ie, patients) to pay for EMR. Industry should not be allowed to avoid funding this system, simply because it is difficult, and a form of taxation, perhaps administered through the Food and Drug Administration should be implemented.

Ultimately, government will need to partner with private industry in the information technology sector, as well as pharmaceutical and medical-device companies, to both fund and structure such an ambitious undertaking.

Goals of the System

The main goal in developing a universal EMR system is access. Although each patient's medical record should be managed by their local primary care physician, patient information needs to be portable and accessible to appropriate caregivers in emergency rooms and other tertiary care settings, while assuring privacy and security to patients. Thus, an internet-based, password-protected records system is most likely the best option. Portable USB drives are another option. Patients could carry their entire medical history around their wrist or neck and it could be accessed by physicians through a common, standardized system.

Facilitating this level of access is key in providing more effective and efficient treatment to patients. Once this is accomplished, secondary concerns such as cost-effectiveness will result from overall better outcomes that reduce hospitalizations and lower the overall utilization of healthcare resources.

Critiquing a Current Model

In October of 2007, Microsoft launched the HealthVault intitiative, which they have billed as "a software and services platform aimed at helping people better manage their health information." Even more recently, Google, in February 2008, announced a long-anticipated health web site to manage personal health records to be available later this year.

The Microsoft model creates a platform for uniform EMRs and positions them as a personal health information system that is not physician-managed. Throughout their press literature, they designate the major health family manager as "the Mom." Microsoft's assertion is that the average family health manager needs to navigate through medical information and decision making.

However, patients generally seek medical attention to be relieved of responsibility, not to take it on. This role is a tremendous amount to ask of family members, who are at varying levels of education and dedication to ensuring the well-being of their families.

A better model would involve the primary care physician partnering with the patient to manage information. For the most part, when patients ask about their options and doctors lay them out, their response is to ask the doctor "if you were me, what would you do."

The Microsoft HealthVault system does not acknowledge that patients are not the managers and ultimately do not want to be managers of their own healthcare. Further, allowing patients full control creates a risk that they will elect not to share information with physicians, which may be detrimental to their long-term care.

Finally, the financial model for the HealthVault system furnishes it as a free service to consumers. However, Microsoft plans to pay for and profit from this service by providing a healthcare search engine to help consumers research healthcare problems, and that search function will "provide ads that are an important part of the user experience." By allowing pharmaceutical advertising as a part of patient self-education, undue influence on decision making is facilitated.

Structuring Information

A common structure for EMRs must also be determined in order to promote efficiency in data entry, thorough and complete patient data, and uniformity across institutions. To some institutions, the concept of an EMR simply means typing notes into a blank template, which is no different from a longhand chart system. When physicians are required to work in this manner, they take short cuts because they have limited time and they structure information in whatever way they want. In order to be universal and efficient, EMRs need to be as uniform as possible and to prompt physicians through the necessary information. The best EMR system would be one that provides a template for essential information and the ability to click through the basic data, rather than writing it out.

Providing Access

The switch to EMRs presents an enormous capital investment for many hospitals and other institutions throughout the country. Creating a basic, universal EMR system that is accessible to any institution, regardless of their current technological infrastructure, is another important consideration. Again, a secure, internet-based system most likely provides the best answer to the problem of inconsistent funding across institutions. If a basic EMR structure can be provided online, it will allow for participation by all institutions at a rudimentary level. Institutions will then be able to add levels of functionality as their own technological abilities allow. One fallacy of universal healthcare initiatives is the idea that comparative care can be provided across the country. Because of funding issues and issues of socioeconomic empowerment, complete equality of care will never be attainable. With regard to EMRs, the basic infrastructure must be put in place for different institutions to access them at their own levels and elaborate them incrementally, at their own pace.

Research Possibilities

The implementation of a unified, national EMR system could facilitate the aggregation of an enormous amount of medical information and result in a valuable database that would dwarf the insurance- and HMO-based databases and sponsored registries that are utilized currently in research. Data derived from controlled trials will always be of tantamount importance in advancing our understanding and moving evidence-based medicine forward. However, a database of the magnitude potentially provided by universal EMRs could be utilized to examine new and established therapies in the clinical setting and see if they are truly successful in improving outcomes. This sort of information can be of great use, as has been seen in retrospective study of the use of drug-eluting stents versus coronary bypass surgery. It was originally thought that stents would allow for the avoidance of surgery and improved quality of life among patients with coronary heart disease. In retrospective study, this has not always proven true, and the move from bypass surgery to stents is now being reconsidered in some patients.

Drug safety, again, is initially determined in controlled trials. However, controlled trials examine a limited number of patients for a limited time span, which in turn limits their applicability, particularly in chronic illnesses with indefinite treatment courses. In these scenarios, it is important to look at larger databases after a drug has been marketed. In the real world, drugs are used in larger populations for longer periods of time and often for slightly different, off-label indications, all of which can affect their safety and require continued monitoring. When infliximab was first brought to market, safety information was available for approximately 300 patients. Now, with continued tracking through registry programs, there is a wealth of information available on over 1 million patients who have been treated over the last 10 years. We need to look at controlled trials as a starting point in establishing safety, not as a definitive test. A universal EMR system would be instrumental in allowing us to do so.

Summary

The development of a national EMR system that is accessible to patients and physicians, yet secure in protecting personal information, would represent a major advance in the ongoing process of US healthcare reform. The federal government must ensure utilization of the system and partner with industry to provide funding and technical know-how, so that an effective system is developed. Without a governmental mandate that ensures universal access and security and avoids the advertising agendas of the pharmaceutical industry, no proposed system can be successful. A universal system that provides access across venues and can aggregate patient data will create cost savings by streamlining administrative systems and promoting better outcomes that translate to less utilization of overall resources. In addition, it can be a valuable research tool, providing steadily accumulating data on the efficacy and safety of new procedures and medications in the real-world setting.

Suggested Reading

Ozcan YA, Kazley AS. Do hospitals with electronic medical records (EMRs) provide higher quality care? An examination of three clinical conditions. Med Care Res Rev. 2008 Feb 14; [Epub ahead of print] [[PubMed] Google Scholar]

Cascardo DC. Bringing it to the next level: how to make your EMR implementation a success. J Med Pract Manage. 2007;23:182-185. [[PubMed] Google Scholar]

Nemeth LS, Feifer C, Stuart GW, Ornstein SM. Implementing change in primary care practices using electronic medical records: a conceptual framework. Implement Sci. 2008;3:3 [Epub ahead of print] [[PMC free article] [PubMed] Google Scholar]

Zickmund SL, Hess R, Bryce CL, McTigue K, Olshansky E, et al. Interest in the use of computerized patient portals: role of the provider-patient relationship. J Gen Intern Med. 2008;23(Suppl 1):20-26. [[PMC free article] [PubMed] Google Scholar]

Callan CM, DeShazo CV. How to navigate health care information technology and electronic medical records. Physician Exec. 2007;33:36-38. 40-42. [[PubMed] Google Scholar]

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Developing Universal Electronic Medical Records

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The idea of healthcare reform has been part of our national agenda for years, and members of both the legislative and medical communities, along with the general public, agree wholeheartedly that it needs to be addressed.

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What Really Brought Down the Boeing 737 Max? (Published 2019)

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Malfunctions caused two deadly crashes. But an industry that puts unprepared pilots in the cockpit is just as guilty.

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