By F. Shawn. Sarah Lawrence College.

Connectivity makes all organizations more transparent and ac- countable to customers generic 25mg precose amex diabetic diet zone. Health plans that embrace the need for openness and responsiveness will find their position in the health system strengthened in future years cheap precose 50 mg on-line blood glucose reading chart. The health plans that succeed in the digital transformation will not only survive, but also prosper. How government responds to these political pressures and how it structures payment for health services under the Medicare and Medicaid programs will affect both the speed and universality of the changes discussed in this book. Changing healthcare payment methodology Each of these issues will be discussed below. Personal health informa- tion is the most intimate documentary information that exists in the 145 U. Someone with access to this information knows a person’s most carefully guarded secrets—personal medical and psy- chiatric history, sexual orientation and history, lifestyles and their risks, drug history, and a lot of things about relationships with others. Insurers who see the totality of someone’s healthcare use can use that information to estimate how good or bad an insurance risk he or she may be in the future and decide not only if they wish to provide coverage, but also how much to charge for it. That patients disclose this information to physicians is vital to ensuring optimal care. Physicians require it because making intel- ligent treatment decisions is based on understanding medical and personal history and the impact of those decisions on health. If physicians cannot be trusted with intimate personal knowledge, the opportu- nity for injury or death escalates alarmingly. Yet this intimate doctor-patient relationship is really a three-way relationship, in which only two of the parties are physically present. Despite its intimacy, medical information is also among the most widely distributed and poorly protected personal information in our society. Thanks to federal legislation passed in the wake of the highly publicized Congressional hearings of Supreme Court Justice Clarence Thomas, video rental records were actually safer from dis- closure than a patient’s medical records. The main reason is that health costs have grown to the point that they are no longer an affordable personal respon- sibility. As a direct consequence, third parties, typically employers and the health insurers they hire to manage their health costs, de- mand access to this information. With the growth in managed care, health plans use personal health information to establish whether the healthcare they pay for is necessary and appropriate. Because insurers and employers have an economic incentive to minimize their outlays, their interest in obtaining personal medical information has acquired a pungent adversarial odor. Employers with access to employees’ health history may decide they no longer 146 Digital Medicine wish to employ someone or invest in training or promoting that person into a leadership position to avoid being responsible for their medical costs. When someone sees a physician or visits a hospital, he or she is typically required to sign a release that authorizes the provider to release whatever information the health insurer may require to review the medical claim arising from the visit. The result is a legal authorization for the physician to breach medical confidentiality in order to get paid. The information patients authorize physicians to release is not only compared to the health plan’s contract to ensure that the service is covered by the health plan. It is also compared to the informa- tion provided about the employee’s medical history when he or she enrolled in the health plan. The purpose of this review is to determine if the condition for which the patient is being treated predates enrollment in the health plan. If it does, but the employee did not disclose that precondi- tion, the plan can not only refuse to pay the claim, but it may also move to invalidate coverage on the grounds that the employee misrepresented his or her health status.

The medical model simply medicalises problems of living 25 mg precose diabetes symptoms not diabetic, of which drinking too much is a symptom order precose 50mg overnight delivery diabetes mellitus zuckerwerte. The most eloquent refutation of the concept of alcoholism 180 as a disease is provided by Thomas Szasz. While excessive drinking may cause disease, it does not follow that drinking itself is a disease. There is no doubt that pleasures carry risks, but it is equally true that where there is no risk there is no fun. At a meeting sponsored by the Committee of Smoking and Health of the Medical Society of the District of Columbia, an ethicist explained that smoking was inherently immoral since it violated at least three fundamental moral principles. Smoking is a complex behaviour, with little understood neurophysiological and psychological mechanisms. A smoker of 20 cigarettes a day for 50 years will smoke 365,000 ciga- rettes, which, if laid end to end, would stretch 30 kilometres. Assuming an average of 15 puffs per cigarette, the smoker inhales five million puffs. With the alleged 5,000 poisonous substances in smoke, he receives 25 billion doses. What is surprising is that many smokers survive this chronic poisoning relatively unscathed. The awesome intensity of the war against tobacco in all its forms cannot be accounted for simply by referring to certain epidemiological reports which have shown that smokers are more likely to die of lung cancer than of some other diseases. They pose new questions about the relationship between the state and the individual, about the right to privacy and about the legislation of morality. Where is the boundary between information and propaganda, between education and coercion? In 1988, according to a count in the British Medical Jour- nal, Australian newspapers alone carried 1,600 items about 185 smoking, of which 83 per cent disseminated fear. The British Health Education Authority raised objections to films which depicted smokers, even though most of them were portrayed as villains. Health educators regularly complain to news- papers which feature photographs of smokers. Einstein with a pipe will not do: the pipe should be skilfully retouched from the photograph so that young readers will not be cor- rupted. They used to do this with the images of Trotsky in historical photographs from the Soviet Union. The continuous barrage of anti-smoking propaganda uses the promise of better health as its ostensible aim. The cam- paign, however, has gradually degenerated into a single-issue fanaticism. As the majority of smokers now belong to low- income groups, the anti-smoking crusade of the new ruling class, who control media and education, has encountered little resistance among the middle classes, even when its rhet- oric changes from coercive altruism to plain abuse. The shift from medical aspects of smoking to moral exhortation only became possible when smoking declined among the middle classes (the upper classes have generally kept aloof and amused) and was further facilitated by the rise of neopuritanism. Samuel Butler in The Way of All Flesh commented on the absence of any Biblical injunction against smoking: It had not yet been discovered [but] it was possible that God knew Paul would have forbidden smoking, and had purposely arranged the discovery of tobacco for a period at which Paul should no longer be living.

When physicians do automate discount precose 50mg without a prescription diabetes protocol program, if no compatibility standards are set in advance buy discount precose 25mg line managing diabetes newsletter, they will use incompatible software and be unable to move clinical information between their systems and those of the hospital. Optimal patient care would require that the clinical team be able to access important clinical information about a patient at any place and at any time. Because hospitals have capital, and physicians, generally speaking, do not, hospitals could be a potential source for modern digital clinical information systems, as well as patient care support tools like disease management, for their physicians. If hospitals could help bring about a shared record format across their medical staffs, it would be easier for physicians to send patient information to one another for consultative purposes. Historically, physicians have been extremely reluctant to permit hospitals access to their private practices. Many experiments by hos- pitals during the 1990s with salaried employment of physicians and with practice management support ended in costly failure. Physi- cians resisted installing inexpensive software that enabled them to perform remote order entry or retrieval of test results from hospi- tals because they thought it opened a portal that enabled hospital executives to understand their practice’s economics. Legal and Regulatory Barriers Besides the mistrust discussed above, legal and regulatory barriers make linking hospitals and physicians difficult. Federal Medicare regulations forbid hospitals from offering physicians anything of value (including software and services) if it would influence their patterns of hospital utilization. These statutes were intended to pre- vent hospitals from, in effect, bribing physicians to bring their pa- tients in. If compatible clinical software made it easier for physicians 86 Digital Medicine with a choice to use the facility that provided them the software, it might trigger fraud and abuse investigations. Tax laws provide another barrier to the sharing of clinical soft- ware between hospitals and physicians. The Internal Revenue Code and state laws forbid not-for-profit hospitals (recall that 85 percent of all community hospitals are not-for-profit) from giving physicians (or anyone else) anything of value. Competitive advantage for specific providers could be eliminated by regulation that requires clinical information systems developed by different vendors to interoper- ate (that is, to use common record formats, coding conventions, messaging standards, etc. This would mean that, once installed, physicians could use their clinical software in conjunction with any of the available local hospitals or retrieve information about their patients from any of them. The fact that software and services could be provided on a dial- in basis without significant capital expenditures by hospitals on the physicians’ behalf could help change some of the equation as well. The most expensive part of a physician office’s digital conversion is transferring all of its existing patient records to digital form so they can be used by the information system. If these costs can be surmounted and physicians can obtain password-protected access to computerized patient records and clinical decision support from their offices, it would be a major boost to overall computerization. Hospitals and Physicians Digitizing Patient Records Together Ideally, hospitals and physicians should move together to digitize patient records. Technical opportunities exist for hospitals to create Physicians 87 virtual private networks that segregate the physician’s clinical records from those of the hospital (as well as the rest of the Internet), protect the physician’s business autonomy and privacy, and still provide the transparency of information flow that is needed for optimal patient care. Physicians have to be willing to wade into the battle over how digital medicine is organized and be assured that their concerns about autonomy and privacy are recognized. When you sum the potential impact of various information tech- nologies across the physician’s world, the aggregate impact is im- pressive. Speed the flow of new knowledge to physicians and store it efficiently so physicians don’t have to rely on their memories 2. Guide and assist in patient care itself, wherever the physician or patient may be at the moment 3. Free physicians from paper records and bills, reducing their prac- tice expenses 4.