HIT National Editor

CHICAGO – Top-down and bottom-up presentations and analysis concerning the future of U.S. healthcare were among the most thought-provoking presentations at the recent annual meeting of the Healthcare Information and Management Systems Society (HIMSS; Chicago), one a look at the political potential and possibilities for healthcare reform, another a debate on the viability of personal health records (PHRs).

Offering the overview of the short- and long-term prospects for reforming America's unsystematic healthcare system was political analyst – acknowledging his need for self-reform, because of being "fat and out-of-shape" – Charlie Cook.

Cook began his analysis by saying that it was "nice to speak to a group in the least damaged part of our national economy," underlining the currently healthy state, not just of healthcare, but of the prospects for health information technology (HIT), driven by the rising interest in making it central to healthcare reform.

In providing a concise analysis of the election of Barack Obama to the highest position in the land, he too like Alan Greenspan in a HIMSS presentation – identified Sept. 15, 2008, as a sort of financial 9/11, and turning Sen. John McCain's difficult job of winning the presidency into an impossibility.

He noted that recent history has shown that after a party's two terms in office it is an 80% probability – four of the last five such occasions – that the American people will want a change. And he said that the "badly damaged brand" of the Republican party by 2008 was further damaged beyond presidential-aspiration-repair with the 9-15-08 meltdown.

In one of the more pointed comments concerning McCain, Cook said that while the senator had managed to identify himself as a "maverick" GOPer – and that the U.S. Air Force hadn't put him "in a single-seat fighter plane for nothing" – a financial crisis of cataclysmic size had resulted in changing the campaign from "roller-coaster" to "watching cement set" and assuring an Obama victory.

As to healthcare reform, Cook said he saw a huge demand for "something to happen" in this area among the mid-range of Americans who were not extremist in either way, and not defining themselves as either Republican or Democrat, but as "independents" and centrists.

But still, he said he expected no "Big Bang" type of changes, meaning a major paradigm-shift, but rather changes that would be "incremental." The reason was that "any funding source [for reform raised] a new set of enemies."

But he said that some changes are possible, both because of continuing public support for Obama and lessons learned from the failures of the Clinton administration to bring them about: primarily putting a greater emphasis on "transparency and openness" in the administration's reform procedures.

In the Q&A period, an attendee asked if Obama might still use the expertise of Tom Daschle in helping to guide reform. Cook saw this as unlikely, acknowledging his obvious expertise in the matter but describing him as potentially unable to "quarterback" the effort because now "damaged goods."

As counterpoint to the standard conference model of straight presentation, HIMSS offered a debate on the viability of PHRs (and by implication vs. EHRs): "against," presented by Kim Slocum, president of KDS Consulting (West Chester, Pennsylvania), "for" by Lory Wood, VP and chief security and compliance officer of Good Health Network (http://security.ghnetwork.com/#).

Slocum said that he had the more "daunting task" in having to take the "con" side of the argument, but that really wasn't the case, playing his part with thespian-like relish, Wood simply reading, often hesitantly, from notes.

Slocum cited studies indicating that PHRs are being used by, at most, just 1% to 2% of patients (and it can hardly be that much), and that the "average" person lacks the necessary computer sophistication to use them.

Wood's primary debate point was that PHRs offer an essential tool for empowering patients to take charge, and responsibility, for managing their own health. But she offered no argument that there is any particular evidence that patients show any interest in using this technology or have the necessary computer savvy to use them properly.

She argued that the "reengineering" of healthcare must be focused on the "patient-provider relationship" and she saw a greater patient "empowerment" in this relationship, slow adoption by providers of HIT and the ability of PHRs to move HIT forward.

"The key jumpstart is to enable patients to develop the appropriate partnership with their provider," with PHRs serving as "an invaluable resource to empower patients to become active partners with their providers."

Slocum countered by emphasizing the need to use the current point in time – and by implication the current political and financial alignment of stars – as a very large single chance to reform U.S. healthcare, and that the pursuit of PHR technology is a false start, compared to EHRs.

He compared the Wood's vision of the savvy and sophisticated healthcare consumer – and by implication the viability of PHR tech – to a "unicorn much-described in the literature, rarely seen in real life."

He described the average American as not particularly sophisticated and having only a 6^th to 8^th grade reading level, and so hardly a large or viable target audience for this technology.

Other issues he noted was the plethora of PHR system architectures, disagreements concerning the difficulties of consistently describing diseases (one being wrestled with concerning EHRs by healthcare itself), issues of information ownership and system security, and – perhaps most important of all – the accuracy of the information in a PHR, with patients not particularly willing to disclose information that might be considered detrimental.

In summary, Slocum argued that pursuing PHR technology was a matter of putting "the cart before the horse."

In response, Wood said that educated healthcare consumers would put "a saddle" on the PHR horse and use it to push the HIT cart forward.