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Clinical Decision Making Under Conditions of Severe Uncertainty: The Info-Gap Solution

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By Robert B. Teague, MD

August 28, 2005

“The pump don't work, ‘cause the vandals took the handles.”

The Subterranean Homesick Blues. An illness or a song? One of the great joys of the Net is access to content whenever and wherever I want it. Access for example to the writing of Bob Dylan--by turns insightful, playful, and inspiring. Or I can get access to ancient philosophies. One of the few things I can't get access to is my own healthcare information. Oh, yeah, I think I am sick.

…healthcare don't work, ‘cause the vandals took the handles.

What handles? Access. The Net returns the beginnings of access to consumers. The first crack in a very thick wall that has systematically guarded health information…your personal information and topical information…by those with the keys to the system for the past sixty years or so, maybe forever in human history.

It is not much of a stretch to say that in human history no society has ever managed to provide enough health care to satiate demand. In fact, some policies may be interpreted as creating demand. But from the twentieth century onward at least the underlying philosophy of governments and providers worldwide has been to limit access to care. If you can't access healthcare, then no one has to pay for it. Voila!! Cost control in healthcare. Unfortunately, restricting access has never worked.

Witness the ever-increasing price of healthcare. Price is different from the cost. But rudimentary economic principle dictates that if access to something that is highly valued like healthcare is restricted--artificially or otherwise--the price will relentlessly go up.

You don't want to believe that there is an underlying philosophy of restriction of access? How about this remark from Victor Fuchs in Health Affairs a few years ago: Over the long haul, there is only one reliable way to slow spending growth: slow the growth of services to patients…the most important strategy for slowing that growth must be to slow the development and diffusion of new technology (Victor R. Fuchs Health Affairs. Vol..18, No.1,Jan/Feb., 1999, pages 15,16).

Fuch's pronouncement is a reasonably widely accepted belief around the world in health policy circles. Is that what anyone really wants? Restriction of access to innovation and improvements? There are other ways to address price besides artificial restriction of access.

We know that individuals seek information about their own health and are willing to engage the process. Excluding pornography, the most highly visited content sites on the Net as reported by Pew Research and Health Affairs are news and science and health sites. Net availability is approaching universality in the United States. Large numbers of individuals visit health sites for general information, wellness tips, and specific information concerning personal health problems.

An example of extreme demand is reported in Sunday's New York Times by Melanie Warner who writes about Natural Cures "They" Don't Want You to Know About, a book by a reported ex-convict for fraud, Kevin Trudeau.

She reports that this is the second best selling book in recent days (beaten only by the new Harry Potter book). So we know people seek information and that whatever is being dished up by the current health care system is vastly incomplete and non-satisfying prompting individuals to seek whatever information they can. Might there also be a trust problem with more traditional sources of information and care?

What seems to be missing is the support needed to reach “informed judgment.” There is way more information available than can by reasonably assessed by one person. How to create the context for your current circumstance out of the various pieces of information available? And how will access occur?

Recent law (HIPAA and others) has established that your personal health information belongs to you. Unfortunately, the media that it exists on does not. Since we live in a health world of complex regulation, perhaps one could be that the owner of the media (doctors, hospitals, health plans) must provide your personal information on demand by any of several methods including the Net.

Many industrial giants are interested in helping you with this access. Intel recently announced it would pursue healthcare in a major way. As reported by Dan Farber on ZDNet Louis Burns, the VP and general manager of the Digital Health Group at Intel, laid out Intel's strategy to improve healthcare by making personal health information accessible to individuals. In addition to access, improved safety and efficiency were sited as motivations.

What's needed for this to happen? A focus on giving each individual access to their personal health information whenever and wherever they need or want it is a first step. Legacy replacement and data integration for institutional health providers and physicians is another step. The information has to be technologically accessible. This will be difficult in an industry that has always underinvested in information technology and services research and development. Security and privacy assurance are large considerations as well.

None of this is easy. Some of it is simple in concept. The hurdles are mostly of our own making, which theoretically means we can remove them as well. But for each hurdle there is someone who has an interest in the status quo. The focus should be on access for now. Turning the tide on a hundred years of philosophical footing designed to prevent access will not be easy.

Robert B. Teague is a pulmonologist and business consultant who is based in Houston, Texas. E-mail him.

Read other blogs in this series.