What might be some of the long-term effects of patient-facing technology (such as apps that measure blood sugar levels or tell patients to refill their prescriptions)? How is such technol- ogy likely to affect the cost of healthcare? How might it affect access to healthcare?

Pay-for-performance reimbursements Evidence from several countries points to fixed-provider payment as a way to reduce the over-use of technology and encour- age adherence to EBM guidelines. This has been done in the UK in conjunction with a pay-for-performance reimbursement system. This type of system eliminates financial incentives to use technology and instead rewards the provider for health out- comes. The physician with the best health outcomes might be paid more than another doctor who provided the same treatment but did not have the same success.

The health industry has developed various quality measures, which generally fall into four categories:

1. Process measures—Measures that “assess the performance of activities that have been dem- onstrated to contribute to positive health outcomes for patients” (Fleming, 2012, p. 1). This might include whether patients who smoke were counseled on ways to quit smoking.

2. Outcome measures—Measures that account for the effects of the “process” activities. In the smoking example, this measurement indicates whether or not the individual quit smoking following the advice to do so. Rewarding or penalizing healthcare professionals for this cat- egory is controversial because the outcome of process measures, such as smoking cessation, is often dependent on social contexts.

3. Patient-experience measures—Measures that “assess patients’ perceptions of the quality of care they have received and their satisfaction with the care experience” (Fleming, 2012, p. 1). Although these measures are subjective, they are still important; until recently the patient’s experience was largely ignored.

4. Structure measures—Measures that directly evaluate the facilities, personnel, and equip- ment used in patient care. An example of this would be the recent initiatives which were tied to the Affordable Care Act (ACA) that rewarded health professionals for adopting technolo- gies that aimed to improve the safety and protection of patient information. (See the section on Electronic Health Records.)

A system based on financially rewarding physicians for good practices and outcomes rather than for their use of technology has shown mixed results in the United States. One study found that in the short-term such a program was successful and had high compliance rates, but that success was not sustained over the long term (Werner & Dudley, 2012). Another study found that penal- ties for not meeting particular quality measures were not significant enough to motivate pro- viders to comply (McKinney, 2013). Most policymakers favor some sort of pay-for-performance reimbursement system as a means of establishing more accountability in the use of technology.

Earlier disease-detection capabilities A system that offers incentives for outcomes such as pay-for-performance also includes a push for the use of technologies that provide for earlier disease detection. One example of detection technology occurred at the University of Michigan where researchers used imaging equipment to

David McNew/Stringer/Getty Images

▲ Smoking cessation is an example of a positive health outcome for which a physician would be reimbursed in a pay- for-performance reimbursement system.

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detect eye disease at a very early stage (Davison, 2008). These researchers developed a technique that could pick up signs of serious problems, such as glaucoma, early enough for patients to be treated before their vision was affected.

Early treatment of any disease has a greater chance of success, and early detection of disease has not only clinical benefits for the patient, but also economic benefits for the healthcare provider. Early detection and treatment often lead to shorter, less invasive regimes for the patient and can reduce overall healthcare costs. Proactive screening programs have proven effective, and tests such as mammograms, PAP smears, and colonoscopies have saved countless lives. Yet many dis- eases are difficult to diagnose early, and this is the area where technological innovation is vital. For example, a blood test can detect pancreatic cancer, but by the time blood levels are high enough to be consistently detected, the cancer is usually in a late stage when effective treatment options are limited. Similarly, lung tumors frequently advance before reaching the threshold size for detection by imaging.

Although in the short term these early detecting technologies and screenings are expensive, in the long term their cost-savings benefits are undeniable. For example, one study found that the early stages of colon cancer cost significantly less to treat. Specifically, at Stage 0 when the can- cer is limited to a single layer of cells in the colon and has not spread to other parts of the body, treatment is estimated to cost around $7,000; the cost almost doubles once the cancer is at the regional stage (i.e., spread to nearby lymph nodes), largely because of the costs of chemotherapy at advanced stages of the disease (Mariotto, Yabroff, Shao, Feuer, & Brown, 2011).

Monitoring from insurers Who decides when certain screenings for diseases should be administered? Insurance compa- nies and government-assisted programs (i.e., Medicare and Medicaid) play an important role in the decision, ensuring that technology is being used efficiently, effectively, and equitably in healthcare. As such, insurers are developing guidelines based on evidenced-based medicine for reimbursements.

When the FDA approves new healthcare technologies, insurers must assess how and if to incor- porate them into an insurance plan. This decision includes not only whether to cover the new technology, but also at what reimbursement rate. Most private insurance companies call upon the expertise of technology-assessment organizations. These expert consultants evaluate the sci- entific evidence supporting a particular technology (American Academy of Actuaries [AAA], 2008; Drummond et al., 2012). Other resources for assessment include federally funded assess- ment centers, most often housed at various universities.

Unlike other countries, the United States conducts most activities related to health technol- ogy assessment (HTA) in the private sector. In contrast, countries such as Sweden and Canada employ centralized government assessment agencies to evaluate the efficacy and safety of new medical technologies. HTA places efficacy and safety as its highest priorities, and all new tech- nologies are evaluated based on this criteria. In terms of medical technology, efficacy can be measured as the health benefit derived from the use of a particular technology. Insurers often ask questions such as, “What is the likelihood that the same outcome can result from a different procedure?”

The safety of a particular technology is also evaluated; assessors determine whether the poten- tial benefits outweigh any potential harm. For example, CT scans expose patients to radiation. However, the benefit of early detection and its overall diagnostic value are believed to outweigh

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the harm from radiation emissions. Nonetheless, HTA recommends that the patient’s exposure to radiation be considered when such a test is ordered.

Finally, cost-effectiveness is also relevant to a health technology assessment. In this area, moni- toring becomes less clear. Whereas it is relatively straightforward to determine whether a tech- nology is safe and effective based on data, assigning a dollar amount to a patient’s improvement in quality or length of life is far more subjective. Generally, the costs of any new technology are at first expected to exceed its benefits. However, over time cost effectiveness can be achieved when additional benefits equal the additional costs. HTA performs comparative effectiveness studies so that neither the patient nor the provider has to make decisions related to a technology’s cost effectiveness.

How Technology Meets the Need for Accountability

Despite a growing reliance on technology, one of the shortcomings of the U.S. healthcare system has been its lack of technology used for the purposes of accountability. This includes practices or activities aimed at inspiring trust and confidence in the population served by a given healthcare system. A prime example of this is the way patient data is collected and stored, including in the form of patient records, disease registries, and data used by hospitals and ambulatory care facili- ties, insurers, and public health studies. It has long been believed that “good information about patients, their care, and outcomes” is essential to improving health outcomes (IOM, 2013). What is new is the use of technology to achieve this goal.

Electronic health records Until recently, providers did not have a central location to see a patient’s comprehensive records and thus were likely to miss information critical to patient care. For example, if the radiology department discovered that a patient was allergic to barium, this information could not be communicated to the patient’s treat- ing gastroenterologist. As a result, this patient was at risk for a future allergic reac- tion. This lack of “communication” between records was associated with an increase of medical errors, deaths, and injuries in the United States (Berner, Detmer, & Simborg, 2005) and was considered a barrier to effi- cient healthcare.

The goal of reducing preventable medical errors led to re-energized efforts for tech- nological innovation within the healthcare industry. In his 2004 State of the Union message, President George W. Bush said, “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care” (Bush, 2004, para. 54). Following this call for innovation, tremendous progress has been made in the area of elec- tronic health records (EHRs), also referred to as electronic medical records, or EMRs. An EHR is a collection of medical documents that can be shared across different healthcare settings and are stored in a secure database. Given their portability, EHRs can be displayed on a desktop or

B Boissonnet/BSIP/BSIP/Superstock

▲ While electronic health records have tremendous benefits, maintaining system security is a constant challenge.

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tablet computer. The type of information included in these records is the same as paper-based records, but because records are electronic, they can be linked to other databases and programs (e.g., billing).

The main information found in an EHR includes:

• Medical history • Diagnoses • Medications • Immunization dates • Allergies • Radiology images • Lab and test results


Electronic Health Records (EHRs), Medical Identity Theft, and Breaches of Confidentiality

The Second International Summit on the Future of Health Privacy (Health Privacy Summit, 2012) concluded that data in digital form is easier than paper data to be obtained illegally or used against the patient’s wishes given the ease with which it can be shared (one click of a button). This violation of privacy can take the form of medical identity theft—the act of stealing someone’s personal infor- mation in order to receive medical care. It can include getting information to obtain prescription drugs or submitting fraudulent requests for payment to Medicare.

Medical identity theft is more prevalent with the emergence of EHRs. According to The New York Times (as cited in Conrad, 2009), three main access points enable medical identity theft: Social Security numbers; insurance information, such as member IDs and group policy numbers; and healthcare workers illegally using the personal information of patients. EHRs expose greater num- bers of people to sensitive information, and many healthcare workers are not adequately trained in how to protect the information stored in this medium.

Maintaining patient confidentiality has always been a central ethical challenge in healthcare. We share information with healthcare professionals (i.e., doctors, nurses, dentists, etc.) that we might never share with others, even family members. In fact, revealing (even unintentionally) sensitive information could affect someone’s life negatively. At a minimum, embarrassment or humiliation might be the result. However, a breach of trust can also have serious consequences—including the loss of insurance or loss of employment.

Strict confidentiality is central in maintaining a safe environment for sharing sensitive information between a physician and a patient. It also serves as the foundation for the privileged aspect of the doctor–patient relationship. For example, if patients do not feel that confidentiality is being main- tained, they might withhold important information about their health or even abstain from medical care altogether. Until adequate measures are in place to reassure patients that their information is kept private, patient care might suffer in the short term.

Given the ease of transmission, another risk to confidentiality is sharing health information mis- takenly (or unnecessarily) with an unintended party. According to a report from the Second International Summit on the Future of Health Privacy (Health Privacy Summit, 2012), there are more


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Many developments in EHRs can be attributed to government incentives. For instance, the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act authorized incentive payments through Medicare and Medicaid to increase physician adoption of EHR sys- tems. This Act offered doctors’ offices up to $44,000 through Medicare and $63,750 through Medicaid for installing computer systems that met federal standards. Hospitals also became eli- gible to receive additional funding. Following the HITECH Act, in 2010 President Barack Obama announced a five-year plan to encourage doctors and hospitals to adopt computerized medical records by offering access to federal money to help defray the costs of the systems.

Proponents of EHRs argue that this new system manages healthcare more efficiently and accu- rately. Foremost, this method of recording removes the risks caused by illegible handwriting, a major cause of medical errors (Caplan, 2007). Supporters of EHRs also argue that this method saves time. For example, providers do not waste time trying to read illegible handwriting or wait- ing for a written medical record to be mailed or faxed. In the end, most policymakers believe that costs should also be reduced.

Beyond the argument that time saves money, EHRs also • reduce drug expenses (by reducing medication errors, adverse events, and over-utilization), • improve efficiency in radiology and laboratory tests (no duplicate test ordering), • more accurately capture charges (increased revenue), and • decrease billing errors.

A 2005 RAND study predicted that electronic medical records could save the healthcare sys- tem at least $81 billion annually (RAND Corporation, 2005). However, as of 2013, those savings did not come close to reality in the healthcare system at large (Abelson & Creswell, 2013). Even the Department of Veteran Affairs, who did experience significant savings since adopting EHRs, recently announced plans to scale back on their ambitious plans to create a single shared elec- tronic health records system between them and the Department of Defense (Vogel, 2013).

than 25 million “legal acquisitions” per year of an individual’s health records by employers, insurers, the criminal justice system, and other parties as a condition of applying for or obtaining employ- ment, insurance, or public benefits. However, as the authors of this report point out, rarely do these requesting parties require the entire health record.

By default, health records are shared in their entirety, which clearly puts health data in many people’s hands unnecessarily. For example, if employers need to assess whether an employee is physically fit to perform a job at a factory, they do not need to know that the potential employee had her appendix removed and that she has a family history of heart disease (these would all be theoretically included in her EHR). One can foresee how this excess information could become the source of widespread discrimination in employment, life insurance, and other contexts in which par- ticular health conditions might be deemed as liabilities.

Even with safeguards in place, such as the Health Insurance Portability and Accountability Act (HIPAA) of 1996, consumers continue to lack confidence that their health records will be kept pri- vate. According to a recent survey, only 78% of U.S. adults said their physicians should have access to information included in their electronic health records (Harris Interactive, 2010). According to the same survey, only about a third (30%) believed that their insurer should have that same access. News of data breaches has largely been responsible for eroding public trust in the use of technol- ogy for patient health records (Perlroth, 2011).

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If EHRs live up to their promise of reducing medical errors, then they should also reduce the rate of medical malpractice. As a result, EHRs should function more as purely medical documents and less as legal documents. A recent study found that doctors who start using electronic health records are less likely to be sued than their colleagues who stick with traditional paper records (Quinn, Kats, Kleinman, Bates, & Simon, 2012). However, in the short term, some doctors worry that when learning the new systems they will actually make more mistakes, such as writing notes and prescribing drugs in the wrong patient’s record.


Electronic Health Records at Shenandoah Community Health Center

Since the beginning of the computer era, those in healthcare have been searching for ways to replace the antiquated paper system with high-tech electronic record-keeping.

Changing records from paper to electronic seems simple in theory, but it is complicated as evi- denced by the case of a West Virginia health center. The Shenandoah Community Health Center has approximately 30,000 clients who average around 129,000 visits annually. In 2005, the facility had to meet several challenges when it implemented an electronic health record (EHR) system.

For the center, the first step was to assemble a team that represented all facets of the facility. This included representatives from the physicians, nurses, laboratory technicians, specialists, and ancil- lary staff. After the EHR system was selected, the next step was to determine the functionality that should be included in the new system.

The biggest challenge for the team proved to be combining multiple records. Because the facil- ity delivered care in several medical areas (internal medicine, family practice, pediatrics, obstetrics, gynecology, and midwifery), many patients had multiple records—as many as five each. One of the key elements to converting all paper records to electronic versions involved maintaining high-quality patient charts that focused on the patient, not the task of record-keeping.

The team had three requirements for meeting their quality needs:

1. The system should provide several templates for each service area (e.g., internal medicine, family practice).

2. Quick check boxes should be available for faster entry of test results, such as lab work or radiol- ogy tests.

3. The system should allow healthcare providers to enter notes and other essential data about the patient’s concerns and treatments.

Key highlights of the entire process included:

• Selecting a system that was easy to use yet emphasized quality measurements for improved patient care.

• Ensuring that all departments were on the development team. • Ensuring that all personnel, from physicians to lower-level staff, were sufficiently trained on the

components of the system. • Guaranteeing that the technology was customized for efficient workflow and appropriate busi-

ness practices.


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Electronic disease registries Related to electronic health records is the use of technology to track diseases in the form of elec- tronic disease registries. These are electronic collections of data related to patients with specific diagnoses, conditions, or medical procedures. In contrast to an EHR, which tracks all of a doc- tor’s patients, a registry contains data only from a small subpopulation of patients with a specific disease. Unlike an EHR, a disease registry is not a legal document, but rather a “comprehensive disease management strategy” (Simon & Powers, 2004, p. 11).

Disease registries are not new. Paper registries have been used in the past to track important information about a range of conditions, such as cancer and diabetes. Similar to the recogni- tion that patient records could be collected more efficiently, complex computer applications were developed to track patients over time and link them to other patients across diverse geographic locations.

One of the best examples of a disease registry is the national cancer registry. Forty-five states, the District of Columbia, Puerto Rico, and the U.S. Pacific Island jurisdictions receive funding through the Centers for Disease Control and Prevention (CDC) to collect data for their local cancer registry. Medical facilities such as hospitals, doctors’ offices, and pathology laboratories send information about cancer cases to their cancer registry. Most information comes from hos- pitals, where highly trained employees called cancer registrars transfer the information from the patient’s medical record to the registry’s computer software using standard codes. The data are then sent to the central cancer registry. The CDC then combines the data from these local registries to form a national registry. This combined registry enables public health professionals, such as pharmaceuticals and scientists, to understand and address cancer more effectively on a national scale.

Table 10.2 describes the main types of reports produced from disease registries for medical personnel.

Once the system was in place, the facility experienced significant hurdles, which included making sure that the staff had adequate training time before the system went live; ensuring that paper data was entered accurately and appropriately for each client; and maintaining the privacy and confiden- tiality of the EHR system.

The system has been fully operational for several years, but the change process has not ended. The Shenandoah Community Health Center constantly reviews its needs and practices to continue mak- ing improvements. In addition, the center is looking for ways to identify patients who could benefit from health education interventions and consultations on various health issues.

For more details on this case study, see:

HealthIt.gov. (2012). A West Virginia health center discusses implementing electronic health records. http://www.healthit.gov/providers-professionals/shenandoah-community-health-center-case-study.

Critical Thinking Questions

1. Imagine that you are a hospital administrator. How could you overcome the key challenges that are keeping you from adopting an EHR system?

2. Imagine that you are a private physician working on your own in a private rural setting. What are the possible incentives for you to adopt an EHR system?

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Table 10.2: Main types of reports generated by disease registries

Type of report

Patient report

Registry-generated exception report

Progress report

Stratified population report

Information generated

Information is related to a specific condition.

Identifies patients who missed appoint- ments and are overdue for care.

Shows how well the treating physician is doing in delivering care for a particular disease.

Separates patients into categories of risk based on highest need.

Purpose Contains recom- mended assessments for patient care.

Monitors individual care.

Compares patient’s progress for a given treatment.

Enrolls patient in a clinical trial.

Physicians often use the data found in disease registries to generate four main types of reports that they use to inform patient care (Simon & Powers, 2004):

1. Patient report. Provides the treating physician with information related to the specific condition and lists the recommended assessments for patient care. For example, this type of report would state that a patient treated with radiation therapy for prostate cancer should be given a prostate-specific antigen (PSA) blood test every six months to monitor the cancer.

2. Registry generated exception report. Identifies patients who have missed appointments and are overdue for care. For example, if patients are late for their blood tests, this report would alert the treating physician.

3. Progress report. Communicates how well a physician or an overall provider organization (HMO, physicians group, etc.) is doing in delivering care for a specific patient population. For example, it might provide the percentage of patients in remission for prostate cancer fol- lowing a particular treatment associated with the patients and their care teams.

4. Stratified population report. This report “separates patients into various categories of risk in order to target interventions at the patients with the highest needs” (Simon & Powers, 2004, p. 10). This data is often used by physicians to enroll patients in clinical trials when appropriate.

Similar to EHRs, a host of software products and technologies is available to support disease reg- istries, ranging from public domains to commercial software, all with varying costs and features. The competition for the development of new software products to support medical registries continues to fuel the burgeoning health information technology industry (HIT).

Medical devices with continuous monitoring capabilities Through innovations in the field of digital medicine, such as Apple’s wireless wrist monitor for tracking blood pressure, electronic medical devices provide continuous health monitoring to improve patient health. Although the software to use a smartphone for health monitoring is still relatively new, implanted medical devices that communicate health data to an external device using wireless telemetry is commonly used to treat conditions ranging from an irregular heart- beat to diabetes. Often used in other areas such as meteorology and even vending machine tech- nology, telemetry in the context of healthcare gathers data from often remote or inaccessible places and transmits it electronically to a central piece of equipment for monitoring purposes.

One of the most common medical devices using telemetry is a pacemaker. This medical device is implanted in the chest or abdomen of the patient to help control abnormal heart rhythms

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through electrical pulses that prompt the heart to beat at a normal rate (NIH, 2012a). The pace- maker consists of a battery, a computerized generator, and wires with sensors at their tips, known as electrodes. The electrodes measure the heart’s electrical activity and send data through the wires to the computer in the generator. If a patient’s heart rhythm is abnormal, the computer directs the generator to send electrical pulses to the heart. These pulses travel through the wires to reach the heart. Wireless telemetry is then used to send data from the patient’s pacemaker to the treating doctor, who can then make necessary adjustments.

Globally, more than three million people have pacemakers (Wood & Ellenbogen, 2002). These devices have saved lives and improved the quality of life for many people who suffer from certain heart conditions. Although most insurers provide coverage for device therapy, pacemakers are still very costly, with some estimates ranging from $50,000–$100,000 depending on whether the pro- cedure is done as an inpatient or outpatient (Blue Cross Blue Shield of Tennessee [BCBST], n.d.).

Other medical devices capable of providing continuous monitoring are also in the works. For instance, scientists have developed “camera pills” or capsule endoscopy. Patients swallow the biodegradable pills and transmit video from within their bodies (Bilton, 2013). In further areas of medical technology, researchers at Carnegie Mellon University are working on devices that could provide treatment during the ingestion process (Kim, Chun, Whitacre, & Bettinger, 2013).

According to PricewaterhouseCoopers, medical devices are highly regulated by the Food and Drug Administration (FDA), and the manufacturer’s accountability does not stop after the sale (PricewaterhouseCoopers [PwC], 2011). Tough regulation is necessary, especially given cases of network failure. One recent example concerns CareFusion, a global medical technology company that has recalled several products over the past few years. In October 2010, the company recalled approximately 17,000 insulin infusion pumps. These pumps, used to treat diabetes, were found to place patients at risk of serious health consequences or death.

Although medical devices offer invaluable benefits, privacy issues emerge anytime information is transferred electronically. Because they provide continuous monitoring and data transmission, digital devices are particularly vulnerable to breaches of confidentiality.


Medical Devices Bring New Problems

Although medical devices can significantly improve and extend lives, they are accompanied by ethi- cal dilemmas, including quality of life and the right to die.

For example, a cardiac pacemaker might significantly extend the life of an adult suffering from heart disease, but the individual’s quality of life might be seriously compromised and lead to physi- cal, emotional, and financial burdens for the family of the individual (Butler, 2010). Before accepting a device such as a pacemaker, patients, their families, and their physicians need to assess the poten- tial long-term risks versus short-term gains. Not all new technologies are appropriate when the patient’s overall mental, physical, and emotional health will not benefit from them.

These new technologies are also not distributed evenly across socioeconomic classes. Some patients might have the means to improve their quality of life or extend their lives, while others might not. Paradoxically, as technology improves, more people are being denied basic care. Sultz and Young


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Telemedicine As society increasingly expects to access services remotely, telemedicine—the use of telecom- munication to provide healthcare from a distance—is becoming more available. The California Business and Professions Code defines it broadly to include

. . . the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, educa- tion, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facili- tates patient self-management and caregiver support for patients and includes synchro- nous interactions and asynchronous store and forward transfers. (Board of Behavioral Sciences, 2012, para. 2)

Telemedicine reduces many barriers to healthcare, such as distance, transportation, and even the availability of particular services in one’s area. This is of particular relevance to rural com- munities who often have less access to medical services than their urban counterparts. Examples of telemedicine in acute medicine include psychotherapy over the telephone or by videoconfer- ence and in-home care of elderly patients (Egan, 2010; Novotney, 2011). Studies of the efficacy of telemedicine have shown it to be a good alternative to face-to-face healthcare. In fact, one study found that psychotherapy via telemedicine reduces the stigma often associated with seek- ing mental health services (Ludman, Simon, Tutty, & Von Korff, 2007).

(2011) have referred to this as the “tyranny of technology” (p. 22). They note that many health pro- fessionals become so “mesmerized” by the technology that it often overtakes their basic practices of care. For example, hospitals often allocate the most competent staff and technology to the care of terminal patients. In contrast, fewer resources are given to those patients requiring basic and preventive care. This not only follows the biomedical model of health (see Chapter 1), but also rein- forces the treatment-oriented nature of the U.S. healthcare system over one that makes prevention a priority.

The trend of substituting technology for care can also be observed in the hyper-specialization of U.S. healthcare and the dearth of medical students interested in pursuing primary care, a field of medicine that often utilizes more basic forms of technology. Meanwhile, new subspecializa- tions have emerged as doctors with narrow specialties tend to be rewarded with higher earnings. For instance, orthopedic surgery was once considered a specialty within surgery; now orthopedic surgeons might specialize in one particular part of the body and even one side of the body over another. A pediatric orthopedic surgeon might specialize in arthroscopic techniques for right knees in prepubescent children. Although this represents an extreme example, it nonetheless highlights the endless limits of specializing and the accompanying value placed on medical technology. This hyper-specialization of the medical field makes it more difficult for patients to find general care than specialized care, especially patients with limited financial resources.

To respond to these ethical concerns, the American Medical Association (AMA) and the federal government continue to develop programs to assess the effects of medical advancements. One of the first of these initiatives was the Diagnostic and Therapeutic Technology Assessment program, created as a result of the Technology Assessment Act of 1972. The U.S. Congress early on recog- nized that “it is essential that, to the fullest extent possible, the consequences of technological applications be anticipated, understood and considered in determination of public policy on existing and emerging national problems” (Technology Assessment Act, 1972, § 2 [b]).

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These examples have all been slowly incorporated into insur- ance reimbursement codes, Medicare eligibility, licensing criteria for health professionals, and informed consent guide- lines (Benitez & Jensen, 2002; CMS, 2012c). For instance, Medicare deemed the following health professionals as eli- gible for reimbursement for telemedicine: physician, nurse practitioner, physician assistant, nurse midwife, clinical nurse specialist, clinical psychologist, clinical social worker, and registered dietitian or nutrition professional (American Telemedicine Association [ATA], 2013). More recently, as part of the Affordable Care Act, the Centers for Medicare & Medicaid Services released a publication that outlines the newly approved telemedicine reimbursement codes (2012c). For example, telehealth reimbursement codes now apply to alcohol and substance abuse, depression screening, behav- ioral counseling for sexually transmitted infections, behav- ioral therapy for cardiovascular disease, and behavioral counseling for obesity (CMS, 2012c).

Telemedicine is used increasingly for critical care and emer- gency situations. For example, a program being piloted at the University of California, San Diego, uses telemedicine to reduce the effects on patient care of emergency room over- crowding. An offsite doctor is paged to remotely “link in” to a telemedicine station in the emergency room to see patients. This is done in conjunction with an emergency room nurse who is physically present with the patient (Brubaker, 2013). Other efforts within emergency care utilize telehealth technology to connect emergency departments and ambulances (Bashford, 2011).

The technologies associated with telemedicine are also changing the working lives of health pro- fessionals. For example, if you go to the emergency room in the middle of the night with a broken foot, someone in Australia might review your x-ray, as telemedicine is widely used in radiology. Instead of employing a radiologist overnight, a hospital can outsource this service to a doctor in a country where it is daytime. Such a practice has proven cost-efficient for hospitals, without reducing the quality of care (Clark, Huckman, & Staats, 2012).

Data collection New technologies also make data collection more efficient and effective for healthcare provid- ers and insurers, and for research purposes. Hospital and ambulatory care settings benefit from these technologies in multiple ways. Beyond the financial benefits, providers can better track their patients over time without requiring physical office space. Health records can be transferred and shared easily between healthcare providers, and records can be updated more efficiently. This greater efficiency should also result in cost savings to hospitals and ambulatory care facilities alike. Accreditation of healthcare institutions has the potential to be done remotely and more frequently because travel to the site is not necessary. If providers believe that at any moment they could be reviewed, they are likely to keep more accurate records.

Insurers have taken advantage of recent technologies for both reimbursement purposes and data monitoring. In fact, technology is said to be driving the growth of this industry. A recent


▲ Tele-consultation allows a facility that does not have a neurology department to communicate with one that does, resulting in an immediate diagnosis.

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report by Cognizant, a leading business consulting firm, identified mobile technology and social media as emerging technologies being used in the insurance industry (Kim & Khuntia, 2012). For example, insurers are now using mobile technology and social media to appraise medical claims more efficiently. This modernization effort is largely driven by the industry’s desire to improve customer service among insurers, providers, and patients. Insurance companies rely heavily on the use of electronic records and data.

Clinical researchers use electronic records to access and analyze data remotely, improving effi- ciency and cost. EHRs make data readily available and can potentially facilitate research of a large cohort with a specific condition, such as kidney disease or diabetes.

However, as noted previously, privacy issues arise in sharing patient data electronically for the purpose of research. Indeed, one of greatest concerns of the bioethics community is the improper use of patient information by pharmaceutical companies for both research and targeted advertising.

In 2011, five big drug companies (Pfizer, Merck, Roche, Johnson & Johnson, and Bayer Healthcare) announced plans to use electronic health data gathered from patients of 13 hospital systems across New York State (Eisenberg, 2011). This data is used to identify and enroll participants in drug studies. Recognizing that federal law bans medical providers, hospitals, and insurers from disclosing identifying information such as names, addresses, and Social Security numbers, drug companies have devised a legal strategy to work around this.

The drug companies have offered to pay hospitals between $50,000 and $200,000 per query to compile a list of patients who match a trial’s requirements (Eisenberg, 2011). Once they deter- mine how many patients might qualify and where they are located, the hospital seeks approval from a local ethics board, and then contacts the patients’ doctors. At the end of this process, a drug company has access to personal information only if the patient consents, but consent is not required for the initial database search. Interestingly, physicians and hospitals have largely wel- comed this initiative because it makes them and their hospitals more “attractive research part- ners” (Eisenberg, 2011). However, it raises significant ethical concerns for patients. In particular, data breaches and the potential for third parties to reconnect names to data (even if patients are anonymous) are just two of the ethical and legal issues.

This fear of data exposure is not without evidence. In 2011, as part of a settlement, UCLA Health System agreed to pay almost $900,000 after two celebrity patients alleged that hospital employees reviewed their medical records without authorization (Hennessy-Fiske, 2010). Although federal and hospital officials would not reveal the names associated with this particular settlement, in 2009 the Ronald Reagan UCLA Medical Center was fined $95,000 for privacy breaches of Michael Jackson’s files. (Jackson was taken to that hospital after his death) (Hennessy-Fiske, 2010). A simi- lar breach was reported to have occurred in 2007 with the medical records of actress Farrah Fawcett (Ornstein, 2008). In this case, information was reportedly sold to the National Enquirer. In fact, the news that her cancer had returned was posted on the tabloid’s website before Fawcett was able to inform her son and closest friends. The hospital fired the employee responsible, and UCLA issued an official statement ensuring the public of its commitment to privacy (UCLA Media Relations, 2008).

Data exposure of individual medical records is not limited to celebrities. The U.S. National Research Council identified insider attacks as the primary threat to patient data privacy. Among the primary threats identified are vengeful employees or insiders who cause accidental disclo- sures, abuse access privileges, or access information for spite or for profit (Knudson, 2013). In theory, misuse of patient data has the potential of endless consequences.

Summary and Resources Chapter 10

Summary and Resources This chapter describes leading medical technologies and their benefits. There is an increased spending in research and development, and the health-tech industry continues to expand. Significant advances are occurring in the areas of pharmaceuticals, medical procedures, medical devices, diagnostic equipment, and information technology. Longer life expectancies associated with particular diseases, improved quality of life, and more efficient sharing of health records can all be attributed to developments in medical technology. Information is also more accessible for patients, and, as a result, patients are now better able to be active participants in their own health management and care.

This chapter also highlights how the use and over-use of technology in healthcare contributes to higher healthcare costs. For instance, the third-party payer system includes few deterrents for the misuse of technology. Also the wide variation in the use of technology has both quality and cost consequences for the U.S. healthcare system.

The Affordable Care Act aims to address some of these issues in order to make the U.S. system more accountable, efficient, effective, and equitable. However, at the core of the U.S. healthcare system is a culture that is characterized by the increased use of medical technologies. Embedded in this culture is the idea that the “newest is always better.” As a result, this poses a challenge to any reform of healthcare.

Compounding these technological challenges are complex ethical and legal issues. Ethical issues about the morality of extending someone’s life without considering aspects of quality are becom- ing increasingly relevant as people are living longer with the assistance of health technologies (e.g., the pacemaker). In terms of the ethical treatment of patient data, ensuring privacy and confidentiality have long been at the forefront of healthcare laws in the United States. However, new technologies such as electronic health records give rise to new ethical and legal challenges. Patients are growing progressively concerned about the measures being taken to ensure the safety of their medical records, especially now that records can be shared within seconds.

To complement this discussion, Chapter 11 compares the United States relative to other health- care systems globally. For example, do other countries have a heavy reliance on medical technol- ogies? How do their health outcomes compare to those of the United States given their different uses of technology? The answers to these questions contribute to a larger understanding of the unique features of the U.S. healthcare system and offer additional lines of inquiry for improving it.

Key Terms

accountability Ensuring that patients, doctors, hospitals, and insurers are responsible for the healthcare they provide, including the costs of technology.

electronic disease registries Electronic collections of data related to patients with specific diagnoses, conditions, or medical procedures. The primary purpose is to serve as a “comprehen- sive disease management strategy” (Simon & Powers, 2004).

electronic health records (EHRs) A collection of medical documents that can be shared across different healthcare settings and are stored in a secure database. An EHR contains medi- cal history, diagnoses, medications, immunization dates, allergies, radiology images, and lab test results.

Summary and Resources Chapter 10

evidence-based medicine (EBM) A set of clinical guidelines that represents the “best prac- tices” and “proven treatments” in healthcare that can serve as a tool for the practice of medicine.

health technology assessment (HTA) The evaluation of the efficacy and safety of new medi- cal technologies by privately funded technology assessment organizations. These expert consul- tants evaluate the scientific evidence supporting a particular technology.

medical technologies A broad array of devices, instruments, or systems related to how medi- cal knowledge is applied. Includes innovations that help people stay healthy, better diagnose disease, treat illness, and provide a better quality of life.

patient-centered A system of care that is characterized by patients playing an active role in their care and decision making rather than being driven solely by the physician. Patients are now active participants in their healthcare rather than passive recipients of care.

patient-facing technology These technologies are broadly defined as policies, processes, or procedures controlled or supported by a healthcare organization that facilitate the access to and use of health information by individuals, family members, and other proxies. One of their goals is to support direct interaction with customers.

physician quality reporting system (PQRS) Part of the Quality Initiatives spearheaded by federal and state agencies and medical associations to assure high-quality, cost-effective health- care for all Americans through accountability and public disclosure.

point-of-care testing (POCT) Technologies that allow patients the ability to test their own vital signs and immediately communicate them to a healthcare professional at a remote location.

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