The infamous “stimulus” bill has about $19 billion in it for implementation of technology to improve safety and connectivity. A substantial portion of that funding is for electronic medical records. Per CNS news, about $5.7 billion in incentive payments has been spent so far.

In order to provide the desired connectivity, either a physical or virtual central repository of healthcare patient information must be established. Per the law, the system is to be established by 2014. The idea of a central repository for all medical records has great merit in an ideal world. No matter where a patient is located, information would be available to health care professionals about past medical history, allergies, current medications, and past surgical history. Since everyone is altruistic in an ideal world and no one would access information that was not required, the system would be wonderful. Clearly, we don’t live in an ideal world.

A central repository of any information of value is a hacker’s dream. The information contained in a central repository would be immensely valuable and 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 likely counter with a back up system of records. A back up system only provides more opportunity to access the information. Even without active hacking of computer safeguards, the records could be compromised by individuals through bribes or other personal motives. This is unfortunately a relatively common occurrence when it comes to national security issues in the United States. Individuals or groups with agendas or political philosophical differences with the government pass information to liberal publications like the Washington Post and New York Times that are known to publish classified or sensitive information. In a relatively recent unrelated example, of the 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 anticipate 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 such a 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 any location 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, but more resource-intensive than, the Department of Defense AHLTA system which is slow, unwieldy, and crashes regularly. A system with that much capability probably doesn’t exist outside of the military or National Security Agency anywhere in the world. An electronic health record system which is slow and undependable would be a danger to patients as necessary patient information would not be available when required. With thousands of access points to the system, there is no practical way to adequately maintain the security of the system. It is similar to building a fence with thousands of gates, any one of which, when breeched, makes the entire system accessible. It is easy to visualize patients avoiding care in order to not have embarrassing diagnoses on the “permanent record”. Currently, your record is in one office. In this future, it is accessible to everyone.

A relatively modern development is the tendency of health care administrators to now view patient care as a “product line”. Physicians are instructed by senior administrators to increase patient throughput even if it increases risk of inadequate diagnosis. When the pressure to increase productivity is present, there is a tendency for anyone under that 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 remain with patients everywhere.

To a cynical person, it seems relatively obvious that all citizen health care information in the hands of the government is not a good idea. While loss of privacy to 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 that 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. Similar arguments have been suggested for bicycle riding for children, obesity and cigarette smoking. The government says, “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 of a centralized system 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. The end result of that information is that 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. The policy will be “Treat the patient in the way you see fit, but we will only pay you if you do it the way we desire.” If patients cannot be treated individually, we might as well scrap the entire health care system and have everyone use a site like WebMD for treatment. There is no reason to talk to patients about their individual situations and examine them in person if it isn’t going to make any difference in what you can do for them.

I believe it would be preferable 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, compartmentalization of records and transmission encryption 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 to establish standards has miniscule costs compared to establishing, building and maintaining a huge overpriced, ineffective system of government 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. It is already occurring. When electronic records become efficient and user-friendly, no one will have to pay incentives to have health care facilities to use them. 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 and there is no reason to assume that it would on this one.

The private sector is always more efficient and should be used to establish these record systems.