Tim, I can imagine several workable funding models for healthcare. The one we have in the US is simply the straightforward "selling services for $", perverted by the brokerage model that insurance has superimposed on it. In my personal opinion, neither model makes sense for a service like healthcare... a service that even the most Scrooge-like among us believe everyone should be have in a time of need.
So I think we are in agreement that a national health service is more socio-ethically correct than the U.S. mercantile model. I have not studied the metrics for success of the NHS model, but your numbers sound credible. We are good at a lot of things in the US, but we seem to struggle with and mostly reject the value proposition inherent in considering the needs of the greater community along with one's own. That's why US feet have so many bullet holes in them! With regard to EHRs of all sizes... yes, they will look different, and if some of those differences were not there, a higher level of interoperability MIGHT result. But again, I contend that it is the DATA that is most desperately in need of a standard. The EHR efforts seem to want to standardize both the data AND the horse it rode in on. I think that is too much... and will simply not be adopted fast enough to ever reach critical mass. The real question is, "Where is the best place to start enforcing a degree of uniformity?" I believe it is best to begin with an understanding of how healthcare processes are alike around the world.... then derive a common set of functional requirements that support the universe of [important/critical] care processes... then build a model of the DATA to support the functional requirements. If we can massively involve providers in such an effort, I believe providers would accept standardizing at the process/requirement level... because they already feel like they are doing that with our published "evidebce-based practice guidelines".... but they will argue til the cows come home about what the darned records should look like! Eventually we might have to create standards for giant data repositories... the big EHR-in-the-sky... but maybe not. If there aren't very many such repository systems, or if a very large one (say, one maintained by the US govt.) made its architecture specifications public, then that might be all the world requires as a de facto standard. We may have too many cooks in the EHR kitchen at the moment. Many of these proposed record models look useful, but which flavor(s) of which ones are likely to become the ubiquitous standard? (The rest will have to go away or risk diluting the success of the ONE... thus, reducing interoperability for ALL). It just doesn't seem to be the right place to be digging for what we are after. Regards, -Chris Christopher J. Feahr, O.D. Optiserv Consulting (Vision Industry) Office: (707) 579-4984 Cell: (707) 529-2268 http://Optiserv.com http://VisionDataStandard.org ----- Original Message ----- From: "Tim Churches" <tc...@optushome.com.au> To: "Christopher Feahr" <chris at optiserv.com> Cc: "Thomas Clark" <tclark at hcsystems.com>; "Thomas Beale" <thomas at deepthought.com.au>; <openehr-technical at openehr.org> Sent: Monday, August 04, 2003 1:16 PM Subject: Re: certification and verification of OpenEHR On Tue, 2003-08-05 at 03:44, Christopher Feahr wrote: > Tim, > RE: "That might be an accurate description of the US healthcare system, > but thankfully the US system is restricted (more or less) to the US, > despite attempts to export it and despite attempts by misguided > politicians elsewhere to copy it....(snip)... Thus, although dreams of > regional or national EHRs seem far-fetched in the US, they are > achievable elsewhere, I think, and perhaps within a decade." > > I share your concerns about the US healthcare model, which differs > mainly in the area of payment. I would say it differs mainly in funding. "Payment" implies a market and transactions, and many healthcare systems just don't operate like that. For example, the public hospital system (about 75% of all acute beds) here in NSW doesn't - they are block funded, not paid on a patient-by-patient basis. Attempts elsewhere to introduce an artifical market into a centraly-funded model eg "funder-provider split" have met with only partial success elsewhere. It is a mistake to assume that the only way to organise the delivery of healthcare is as a market in which services are bought and sold. > Allowing 6000 insurance companies to > become so firmly wedged between patients and providers was NOT a good > idea. The only possible benefit to patients and the common good is > risk-mitigation... something that the US govt. is in a MUCH better > position to do fairly, and something that commercial health plans have > not really given us anyway. In fact "risk mitigation by my rules" being > obviously better than shouldering the full risk, has become the chief > subscriber-retention strategy for many health plans. Some people even > choose to remain in jobs and careers they despise, in order to have SOME > health coverage. Here in Australia the conservative government has had to provide all sorts of absurd tax and financial incentives to induce people to take out private health insurance (which funds access to private hospitals and a few other fringe benefits), and still the take-up is poor (less than 30% with private insurance) - simply because people feel confident that the publicly-funded system will deliver adequate care when they need it (and they are correct). Cost-containment? Our health expenditure is about 8.3% of GDP - well below that of the US. Quality and effectiveness? Population health outcomes here are much bettrer than in teh US, and other quality measures of hospital care are as good or better. Australia is not unique in this respect - most developed countries do better than the US. > > But it took us 40+ years to get into this jam in the US and we cannot > expect to back out of it overnight. If there is anything inherently > "unfair" about the US situation (besides the government failing to > accept its role of chief risk-mitigator) it is the lack of > representation of provider needs in the general area of "information > management" and standards development. I believe that we could live > with the US payer-model if our govt. found a way to even out the $-risk > of health problems for all patients... assure that all Americans had > access to a reasonable level of care... and funded a mechanism for > discovering and publishing provider requirements in the form of at least > a national, if not global standard. Note that even private health insurance here is "community-rated", which means that the insurers are not allowed to charge different fees for different risks i.e. the well subsides the sick. They are allowed to exclude coverage for pre-existing conditions (which are still covered by the public system, of course). The relevance of all this is that the macro-level architecture community EHRs will be driven largely by the organisation of the healthcare ecosystem in which they will exist. Thus US EHRs will necessarily operate quite differently to Australian or UK EHRs. The components of the EHR, such as archetypes or terminologies, might be the same, but the way those components are used will be quite different. Tim C - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
