Jay,

I understand one obstacle to computerized medical records is that doctors are not that fond of creating and updating them. Plus there is the problem that it only takes one inopportune network or computer shutdown to convince both doctor and patient that pen & paper are a better solution.

Another factor is who owns the medical record and who is responsible for archiving it and providing copies of it? This activity has a cost. Who bears it?

When one considers these questions one sees that the economics of digital medical records still need to be worked out.

The roots and fore-runners of telemedicine actually arose in rural US states out of necessity in the '90s. Small cities such as Hays, KS, and smaller health care entities like Great Plains Health Alliance participated in the early programs. It's interesting for me to watch how this particular concept has grown in popularity and scope.

Regarding computerized health records, privacy isn't the only major logistical concern. In some larger hospitals (which shall remain nameless), duelling and duplicate computer databases are used that are incompatible with one another. Trying to have duplicate DB vendors agree on intermediatiary formats and fixes is a very real logistical problem. Hospital IT departments are at times quite large (not just proportionally large to their corresponding institution's size) to juggle and troubleshoot the duplicative systems and the problems that are created that affect billing, pharmacy script processing, research data, etc. On one hand, there is real potential for achievable efficiency and accuracy. On the other hand, it still takes quite a lot of manpower to maintain the systems. Not to mention all the practial training that occurs for all functional hospital staff when it comes to floor nurses, doctors, CNAs, etc.

Don't get me wrong--technology is great and has the potential to help a lot of people. Unfortunately, many people are under the impression that the implementation and existence of these systems is "magical" and requires no maintenance/effort, the systems are always accurate, blah blah blah.....

Laura, you seem very well informed on this matter.

I'm sure there are ways establishing this uniformity could be done more (or less) painfully than others, but in your view what would be required to "mandate" the uniformity?

Could it be ordered as administrative fiat under the aegis of Medicare... or would it require specific enabling legislation?

Thanks for any input you may have.

MrRational, you've hit upon my weakest area--how to best implement and enforce this, legislatively.

I'm leaning toward a specific legislative clause or clauses that creates a department to codify standards and system implementation scope. The reason I mention "clauses" is that I think it is best implemented in a sector-by-sector order within health care institutions. For example, we could implement pharmacy systems first, while starting on development of patient records (a HUGE undertaking, and unfortunately not entirely analagous to Wal-Mart). I don't think it should be over-legislated in the sense that "field A containing congenital diseases A-J should appear in tables 1-13, and on form 93 in the upper right-hand corner". Although I do think standardization and simplification of forms would help EVERYONE in both the paper and digital formats.

I'm not trying to leave you hanging with my answer--it's just my head starts spinning with possibilities, potential roadblocks, and some of the specifics. It's not a bad thing, but it's why I'm not a politician. I can't sound-bite this. :)

As I see it one key issue is medicine is not as exact a science as the technocrats want us to believe it is. The analog world is designed to handle nuance. The digital world is not.

That said the medical community should settle on standards for a database of all patient imagery (ie x-ray, mri, sonograms, etc)

WHY DO YOU USE THE EXPRESSION " DEATH PANELS" IN THE TITLE TO YOUR PIECE ?? EVERYONE KNOWS THAT SUCH "PANELS" HAVE NOT BEEN PROPOSED AND WILL NOT BE. ARE YOU SEEKING TO DRAW IN READERS BY THE USE OF THAT TITLE ? IF SO, YOU DO A DISSERVICE TO YOUR READERS AND LEND CREDENCE TO THOSE WHO ADVANCE THAT NOTION.

Stan -- A good point. The reference was intended to be ironic, but obviously that didn't come across. Yes, I can affirm that there are no death panels in the Democrats' legislation and people who claim there are are deluded or disingenuous.

Stan's prognosis on death panels (HAVE NOT BEEN PROPOSED AND WILL NOT BE) is only half right. The proposals put forth have not specified anything so crass, but no one can predict the future with that level of certainty. The truth is that if costs keep rising at current rates for the sickest patients, they will crowd out all other expenditures and gobble up much of the US GDP. At some point, whether or not the Obama plan is implemented. all providers including the government, private insurers and hospitals (who often get stuck paying for indigent patients) will reach the limits of their ability to pay and will be forced to say "NO" so a substantial number of very sick patients. Sure, some of the improvements in technology will bring down cost per procedure, but these changes and others will also open more opportunities to preserve life by keeping people sicker for longer. I'm still inclined to believe that the latter forces will win out, making death panels (public or private) inevitable. Defeating death is like trying to create a perfect vacuum; the closer you get, the more expensive each percentage of improvement gets.

PCL and Stan, the rhetoric and the obnoxious terms aside... the functions of case management and review already exist.

They exist because they need to exist and (absent some amazing future miracle) will continue to need to exist.

The questions are how honest we are with ourselves about this need, when in the cycle of their application the average person becomes aware of them, how uniformly they are applied across the whole of the population and the aspect which is getting the press today: who is expected to pay the costs to circumvent these care reviews and case management decisions by those who desire to flog and thrash and otherwise torture their loved ones during their last weeks and months.

I don't want to get into an argument about the philosophical or religious basis for those decisions by those few... but I also don't want their outlook to be the default imposed on the majority of us who don't want it and don't want to be coerced into paying the bills for those who do want to torture and flog their loved ones.