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Tuesday, September 16, 2008

Presidential Politics and Healthcare IT

I never expected to attend an international standards meeting in a foreign country and then hear, in the plenary session, a political message from the US Presidential campaign. In an ideal world, standards and politics don't mix. The world I work in is far from ideal, and nothing brought that home more than the political messages of the US candidates compared to the messages presented by Canadian Health Infoway, British Columbia, The EU, Brazil and Singapore. We got to see the healthcare infrastructure that benefit the patients in those regions. The US "report", as it were, brought home how badly behind the US technical infrastructure is for providing healthcare.

Speaking as a volunteer for the McCain campaign was Stephen Parente, PhD, MPH and MSc. He presented the McCain plan for healthcare in four points.
  1. The first incentive is a $2,500 / person, $5,000 / family tax credit. The credit would be paid for by adjusting (removing?) the tax exemption provided on healthcare benefits. It wasn't clear to me whether that meant for individuals or corporations, but I'm sure you could read the McCain plan elsewhere on the web. Stephen asserted that this would be a break even prospect over 10 years. In part the reason it would break even is because the tax credit would be adjusted upwards on the rate of inflation in general, rather than the rate of healthcare cost inflation. In later discussion on this topic, the question of "single payer" came up, and Stephen responded that culturally the US was not ready for that step yet.
  2. Common to both plans was to guarantee access to healthcare for all. I was unable to determine from Stephen's presentation much more beyond that. He did indicate that this would be a fairly large investment, atypical of past Republican initiatives.
  3. Stephen spent some time making the point that the cost of the "same" health insurance plan in different states varies, by as much as 100% in cost. This is due to legislation passed in 1945, before the internet and the mobile populations that we have today. Large corporations have an ERISA exemption to this act. So, this incentive would make it possible for patients to purchase health insurance across state lines.
  4. The last incentive was unclear to me.

In discussions of the opportunities for Healthcare IT related to this plan, Stephen mentioned that the tax incentive could provide some opportunity. He did make the point that spending by consumers based on the tax credit would still be subject to consumer choices. He thought that one opportunity would be to develop a Health card that would enable the exchange of clinical information. He also discussed using and sharing of data available to payers through attachments, such as labs, with other providers, possibly enabled in some way through health cards and authentication technologies available in them.

When I asked a question about how the McCain plan would impact the ongoing work of ONC, including AHIC, HITSP, CCHIT, NHIN, and HISPC, Stephen responded by saying that this "is an open discussion that needs to happen."

Speaking as a volunteer for the Obama campaign was Blackford Middleton, MD, MPH, MSc. Blackford's presentation included highlighting of the three points of the Obama campaign. However, he stared first describing some of what the problems were. Many of us in the standards space have seen this data before, but using it seemed to show some awareness of the audience.

The three key points he touched on included:

  1. All access, and in presentation of data on patient satisfaction with the current system, made the point that US patients are ready for change.
  2. Modernization of the healthcare system. Included in this part of the presentation were some studies reporting where some of the costs are and where the benefits of EHR use go (most of it to others than providers). As part if this point, he discussed the investment of $10B in healthcare IT over 5 years, an investment on par with some of the topics presented by other countries in that session.
  3. Lastly, Blackford discussed connecting healthcare IT providers and public health, focusing on more wellness, instead of illness.

Blackford, when asked the same question about the role of ONC et. al., felt that the role of these organizations would be strengthened under the Obama plan. The opportunities for healthcare IT were discussed under point #2 above.

I found some interesting points in both presentations, but am far from an impartial observer, as I'm pretty well known as a liberal Democrat with regard to healthcare issues. I'll repeat the admonition that opinions mentioned in this blog are my own, and not those of my employer, or any of the organizations the I volunteer with. Some of my own observations follow:

Stephen needed to be introduced, as he's not necessarily well know in HL7 circles. His discussion of Healthcare IT, health cards as an opportunity for fixing the problems, and use of payer data, showed to me disconnect from the work of HL7. He did use the "Attachments" keyword, but that's only one part of a much bigger picture. When I asked the question about ONC and the alphabet soup, I felt his response was a little like a deer caught in the headlights. I found myself strongly questioning how a $2500 / adult tax credit could "trickle up" into investment in Healthcare IT. I also found myself further questioning how a tax credit that simply shifts money from an employer tax exemption to my pocket would change my overall healthcare costs. Those additional expenses need to be paid for in some way, and that will either come out of my benefits or salary increases, or will impact employment.

Blackford is already well known in Healthcare IT circles. He connected with the audience first by reporting on some of the reasons that we need to invest in Healthcare IT. His slides included geeky references to Star Trek and Dilbert. He had a much better story on the opportunities for Healthcare IT for this audience, and I personally think, for patients as well. Blackford is helping to create AHIC 2.0, and is well aware of the role and work of ONC, HITSP, HISPC and CCHIT in the US. Blackford did not discuss the details of the Obama plan, however, a complete document from the Obama campain describing those details was present in the program materials. I wish the McCain campaign had been smart enough to do the same.

Overall, I enjoyed the discussion of the US campaigns approaches to healthcare, but also have to question whether this was an appropriate use of HL7 member's time. If this had been a meeting of the HL7 US Affiliatiation (an imaginary body), I could see where this would fit. Given that this is the Plenary of HL7, I have to question the approach. Next time I'd actually like to see a presentation from what I still like to call the US National program, which would be much more comparable to what we saw from other HL7 member delegations.


  1. As a non-US attendee to the HL7 conference I must admit I skipped the talks of these two presenters. Given the lack of a (currently ficticious) HL7 US it makes sense to have such presentations at an international HL7 conference.
    You forgot to mention that these presentations were followed by a speaker who spoke about European Union eHealth projects. This fits just as well (or not at all) as both US-presentations.

    By the way: I didn't attend the European presentation either - for its contents are pretty well known to me.

  2. As another US attendee at the HL7 conference from the other end of the political spectrum, I have to agree with Keith's remarks.

  3. As a Canadian, I had a couple of thoughts.

    The first was ... what are these two rabbiting on about, and why should I care (other than the usual care level of living next to an elephant)?

    The second was ... a profound thankfulness that I we have socialized medicine, and and a fair amount of ire at BOTH the speakers when they spoke about the poor frivilously spending any tax rebate/voucher.

    While I have not had to make the choice between food and healthcare, I have been a single Mum, and while there are stupid poor - in the same way there are poor rich - I highly doubt that most poor single Mums would rush out and buy a flat screen TV. They would simply use the money for WHATEVER the needs were at the time - medical or otherwise.

    I realize the point that was being made, but the sense of smug entitlement really came through.