Vol. 1. No. 5

It was the fifth day of the month, the fourth month before the end of the year, the end of the century, and, I am told, the end of a millennium. The young woman standing behind me in line at the pharmacy was probably not much older than twenty. Her clothes were appropriate to the New Hampshire early autumn, and clean, but not fancy. I was in line because, although I had called in my prescription ahead of time, the pharmacist had not filled it. "Your insurance has expired," he explained. Through my employer, we had, indeed, changed health care plans within the past few weeks. I shared my new health care benefits card with the cashier, and the pharmacist proceeded to fill my prescription, the entire cost of which would not reach the copayment amount required by either my new or old health plan.

Now the young woman was subjected to the same ritual. "Your insurance has expired, so we didn't fill the prescription." The woman appeared as stunned as I had been at this response. She replied that she knew that it had expired; she was prepared to pay for it herself; her child needed the medicine. The pharmacist began his work at the computer terminal, investigating the formulary. He called to the cashier in a voice loud enough for all to hear, "Does she realize it will be $76?" The young mother's face went slack. She recovered her composure and opened her checkbook. As she reviewed her bank balance, she stated, slowly, "Well, I do have the money, and my baby needs this medicine." Her voice audible only to me, she said softly, but clearly, "There goes the rent."

The pharmacy experience epitomizes the current specter of our health care system as more concerned with patients' ability to pay than with its own responsibility to improve health through services and products. A number of scenarios had not been played out, any one of which would have provided better service, filled prescriptions more efficiently, and avoided public embarrassment. None of the scenarios requires technology any more complicated than the telephone. Why had the pharmacist not called to inform us of our lapsed insurance plans, and determine our desire for filling the prescriptions by some other payment? Why did he not offer a generic medicine to the young woman, or offer to call her physician to determine if an alternative treatment or lesser dosage would suffice? Could he have filled half the prescription at a time?

The glossy media are filled with hopeful and boastful articles about the progress we may expect in the new

millennium. In particular, health care information technology vendors promise their products will prepare us for the new millennium. Well I, for one, probably won't make it very far into the next millennium. Actuaries tell me that, barring any truly groundbreaking advances in health care, I'll push statistical probability to reach half way into the next century. What are our opportunities for affecting events through the next millennium?

Skip back to the beginning of the past millennium. What seminal events transpired a thousand years ago that shaped our current civilization and society? Were the 5,000 soldiers who accompanied William the Conqueror into the Battle of Hastings (October 14, 1066) aware that their victory would decisively establish England's link to Western Europe, setting the stage for the Eurodollar? Were the soldiers in that battle ready for the Crusades? Martin Luther's 95 Theses? The discovery, conquering, and settlement of the continents of the Western Hemisphere? Gutenberg's press? Societies where most, rather than a select few, can read? Electricity? Internal combustion engines? Telephones? Ice cream cones? Airplanes? Radio? The atomic bomb and nuclear energy? Television? A Declaration of Independence? Or the medical advances of Anton van Leuwenhoek, Marcello Malpighi, Crawford Long, Marie Curie, Edward Jenner, or Jonas Salk?

We have seen how quickly information technology has moved in only the last two decades, or just 2% of this past millennium. Technologists only a decade ago had no whisper of the Internet, java scripts, or web browsers and were pursuing revisions of proprietary legacy systems as proprietary client-server applications. How can we prepare for the next five years, let alone one thousand?

We currently grapple with data definitions to describe clinical events and medical status, to establish a computerized patient record and technical interconnectivity to provide for its availability to the team of health care professionals collaborating on a patient's care. There are corollary business, economic, and political issues to be resolved, including each patient's right to privacy. The establishment of computerized patient records, integrated with case and disease management systems, holds the promise (over and above reimbursement and payment systems) for improving the provision of health care to individuals over their lifetime. Medical knowledge and treatment paths, when available to providers at the point of care and based upon accepted medical standards, become the touchstone for customizing treatment for individuals, rather than imposing standard treatments in spite of individual case differences. Aggregated, such information may be the key to understanding and improving the health of a population. The value of a population health database becomes compromised to the extent that it excludes information about diagnoses, treatments, outcomes, or any individuals in the population. In order to benefit all of us, health care must reach each of us.

To truly lay the groundwork for a new millennium, we should challenge ourselves to establish a societal paradigm that ensures that health care advances - clinical and informational technology and indemnifying and delivery systems - are available to promote the health of the population, where an individual's access to health care is no longer a choice between treatment and rent.

About the author: Robert S. Eichler is an expert in managed care operations and systems, functionally analyzing system applications and evaluating system strategies. His talents in system analysis, conversion and operations re-engineering are combined with an ability to communicate technical concepts in layman's language.