In the current issue of the New England Journal of Medicine, Michael Porter, the Strategy Czar from Harvard Business School, has a very interesting manifesto on how to fix the healthcare system. Since it’s a Perspective, the NEJM is letting you read the whole thing for free. For what it’s worth, I’m pretty much in agreement with Porter’s vision on the end-state of healthcare reform. We need to fix payment by bringing everyone into the system (and yes, that more or less means universal coverage, whether by government administration or simple mandate) and we need to restructure the delivery system in a way that creates powerful incentives for care coordination and health maintenance.
Porter suggests we have to start all these changes at the same time, because they’re self-reinforcing. And as I think about it, I have to – perhaps a bit reluctantly – agree. Anybody who has been seriously interested in healthcare reform for any amount of time has invested quite a bit of thought into “process patches” on the existing healthcare system. Personal Health Records are one such, but as promising as it is, consumer controlled healthcare information isn’t going to do more than create some small efficiencies. That may still add up to billion dollar sums, but against a $2 trillion backdrop even the odd billion doesn’t go as far as it used to. There just aren’t enough little fixes to add up to one big fix.
Since this is nominally an informatics blog, I’ll call out Porter’s very sound observation on the role of EHRs:
Sixth, electronic medical records will enable value improvement, but only if they support integrated care and outcome measurement. Simply automating current delivery practices will be a hugely expensive exercise in futility. Among our highest near-term priorities is to finalize and then continuously update health information technology (HIT) standards that include precise data definitions (for diagnoses and treatments, for example), an architecture for aggregating data for each patient over time and across providers, and protocols for seamless communication among systems.
Aggregating data across time and providers may sound scary to anyone concerned with patient privacy, and Porter doesn’t mention that part of the equation at all. If there is going to be systematic reform, the average citizen is going to wonder about its implications for medical confidentiality. One nice thing about universal coverage is that it dramatically reduces “breach consequences” for medical privacy. It doesn’t eliminate them – there will always be conditions that create social awkwardness or worse – but the big threat, loss of health coverage, no longer applies. I’m surprised that isn’t pointed out more often.