Social Organ Donation?

It’s all over the place that facebook is now encouraging users to report their organ donor status, along with all the other stuff in your profile. The San Jose Mercury News has even reported that it’s already increasing registrations in California. What gives?

Nurse: The upshot is that Facebook hopes that asking people to list their organ donor status on their Facebook page will create peer pressure to sign up as a registered donor. This is a potentially good strategy to get people who would be fine with organ donation, but never bothered to sign up, to do it, or at least to think and/or talk about the issue. Especially if Facebook uses their spying/linking/advertising mojo to link you to your DMV. No harm there, right? Interesting– framing organ donation as a social issue.  I can’t really see a valid argument that peer pressure will cause people who aren’t ok with donation to sign up. I don’t see this as controversial, but then again, I’m usually wrong about that kind of thing. . . 

Lawyer: I guess it just depends on whether you see it as a personal/private kind of decision, or whether the “greater good” notion of having a donor registry to begin with really makes it a public-spirited thing anyway. Is it just sort of like the “I voted” sticker that you get on election days? Like the tote bag or bumper sticker that says you gave to NPR? Or is it somehow more private because it’s about your body? I guess I agree that I have a hard time objecting, especially since as I understand it, you can leave it blank, and it never appears. 

Nurse: The interesting question was whether Facebook could ever be used as a source of information for hospitals about the patient’s wishes if they did not officially register. The article suggests that, rather, Facebook could let the family, who makes the decision if the patent didn’t register, know what the patient wanted– essentially that they would have consented. Could it ever lead to a direct use by hospitals of this information? Probably not anytime soon, but it sounds like Facebook is adding more health features to its site– maybe we are moving towards an online “personal health record” style repository of information that could, some day, be useful in that way– but honestly, I don’t see that happening yet.

Lawyer: And ew, would you want it to? I already find it sort of annoying when people use status updates to report on their various symptoms and/or dietary and exercise achievements. A platform that’s created to be social and very adept at trying to sell you things based on your personal information seems like a bad place for personal health information.

As to the consent issue, I think that’s probably right — and it probably would lead to at least some increase in donations, assuming there are a fair number of cases where the family says no because they’re not sure whether the person wanted it. But then, I like all kinds of things on facebook. You have to wonder if any of that could come into play after you’d died. (Imagine leaving a big chunk of money to a charity which, unknown to you, has dispanded before you die; what do they do with the cash? I could see using an online profile to find information about what you would’ve wanted.)

And with my cynic hat temporarily on: Surely they did this to get some good press as a socially positive company in advance of their IPO…?

Take two of these, and hope you don’t get fired.

NYT reports today about some companies who have started including prescription drugs in their random drug testing, and dismissing employees who test positive EVEN WHEN THEY HAVE A VALID PRESCRIPTION.

Nurse: So, random drug testing at work is not news, nor is the fact that these tests often include presription drugs– but what IS significant about this case is that having a valid prescription does not get you off the hook. There are a lot of problems with that, obviously– some drugs are tested for when others are not, people with a legitimate need for a drug can be fired for using it, people who are able to perform their jobs safely are fired out of concern that they could potentially at some point be impaired, maybe others too . .. ?

Lawyer: Also some privacy concerns — your employer doesn’t have a right to know your private health information, whether or not they use that information to fire you. Might deter people from taking their prescribed drugs because they’re afraid of losing jobs.

Nurse: It seems like the entire thing could be conducted through a third-party company. . . and IF the employer was not firing people for legal precriptions they would never know about them, which makes sense. But you’re right, it seems like a privacy violation for your employer to test your urine for various substances that you have a right to use, legally speaking, and then fire you for it, especially because they cannot prove that you are using them at work. If you take a vicodin after work, your urine will test positive for hydrocodone. that’s even less your boss’ business than if you took one at work. Now, this isn’t totally screwball, because there are legitimate concerns that an employee of say, an auto plant could be a danger to herself and others if she was impaired. Many of the medications under discussion (like hydrocodone and oxycodone, which are the narctocics in vidodin and percocet) legitimately can impair your ability to operate machinery, and they are labeled as such.  So sure, I understand the concern.

Lawyer: But. . . is the situation such that one could be a danger to others without exhibiting any signs whatsoever of altered behavior? Is this an across-the-board kind of effect? Nobody can drive safely when intoxicated — but do these drugs affect everyone that way?

Nurse: Well, no, and it matters how  much you’ve taken, what your tolerance is, and your general suceptibility to those side effects. Some people will be totally safe and some will be impaired. But what troubles me is that it is widely practiced to test if there’s cause to do so– someone is behaving strangely, appears impaired,  etc. Why do employers feel this is insufficient? Do they have a leg to stand on, legally? Is it really safer to use random tests than targeted ones?

Lawyer:  I agree that this is very troublesome, especially in jobs that don’t seem to have abnormally high safety risks. The question about a leg to stand on legally is a tricky one, and the NYT article starts to get into some of the problems.

The biggest one that occurred to me on a skim-through was the Americans with Disabilities Act — which forbids employers to fire people for having any kind of disability that don’t significantly interfere with their ability to do their job and even requires the employers to make any reasonable accommodations necessary for disabled employees to work there.
So if you have an employee who needs a strong pain medication. . . you see where I’m going with this. They need a reasonable belief that the person’s condition is interfering with their job. Hence, no need for random testing. Let alone firing.  It seems like they are moving to suggest that a positive result on a random drug screen might constitute grounds for reasonable belief that the person cannot do their job. Nurse, is this feasible? (this is probably shaped by the answer to my question above.)
Nurse:I agree with you that the present standard addresses this. If they have data that shows that a high percentage of employees who are involved in accidents have tested positive for legal precription drugs, then they are adressing a problem (even if they are doing so illegally/imorally/whtever). If not, then they are not, and  this whole thing is bogus.
Lawyer: And yet, the testing is surely expensive, as is the turnover in the work force — they must be finding it somehow worthwhile.
Nurse:And again, if using certain prescription medications makes one inelligible to perform the job, that needs to be an up-front disclosure, right? Ok, so a person with epilepsy cannot be a truck driver. That makes sense. Can a person with pain then not work on an assembly line? If they are going to make that argument, they better do it loudly and before anyone is hired, or has worked there for 20 years. Do you suppose the company in the article has any data to back them up?
Lawyer: This is a good point — if someone does a job perfectly well and safely for 20 years, exhibits no change in behavior, and is fired because of a health condition, that seems pretty indefensible. Changing the rules after someone has made a real investment in signing up with you sure looks bad.
Nurse: Now, I can imagine this being somewhat more complicated among people who have access to such drugs as part of their jobs– nurses, pharmacy techs, etc. For us, a positive drug test is probably somewhat more serious even if there is a legitimate explanation because we are in a position to steal drugs. Having a prescription doesn’t mean you didn’t steal them. I’d like to think people don’t do this, but evidence does not back me up. But even if this more delicate situation, I don’t think it can be justified unless it is proven that your ability to carry out your duties safely is compromised.
Lawyer: I would add that at the very least, I would expect the employer to offer a long-time employee an alternate assignment if they believe a prescribed drug or health condition is interfering with the employee’s ability to safely perform his or her job.
Nurse: Lots of employers, especially in healthcare, offer rehab, repeat testing, etc. for use of illegal drugs or illegally used prescription drugs. That doesn’t make sense if you are talking about a legit precription, but it just goes to show you that there are more lenient pathways that don’t lead to a nation of zombie-employees showing up stoned every day.
Lawyer: Repeat testing doesn’t do the trick here. In fact, this company offered it. But then you’re in a great position: go off the meds your doc prescribed for you for a health condition so you can pass the test, or lose your job.

How much are your eggs worth?

There’s an article on NYT today about payment to egg donors, and how we are (and aren’t) regulating it.

There’s theoretically a voluntary limit of $10K on payments (if there are extraordinary circumstances) and $5K for regular circumstances. And these limits aren’t always adhered to. Some thoughts:

Nurse: The major issue with large payments is that it can become essentialy coercive, becoming so enticing that potential donors overlook the risks and moral questions in order to receive a large payment. This issue comes up in paying research subjects, too– in either scenario, they could be seen as “preying” on poor people. It can undermine true informed consent.

Lawyer: And it calls up the issues we’ve discussed concerning organs. Sure, there are some differences — eggs aren’t serving any function in your body, etc — but in a lot of ways, they’re the same. We’ve decided as a society that you can sell your eggs or sperm, but not your kidney. That you can decide to donate your organs, but not sell them. These are all just rules we’ve made, for lots of policy reasons, including coercion and a general feeling of sanctity of life.

Nurse: Do women understand what the physical process involves? i think in some cases they may not until they have already decided to do it for the money.

Lawyer: And part of what this article is concerned about is a “bait and switch” that happens — the ad says 10K, or even 50K, and you call them up, and then they negotiate it way down.

Nurse: They get hormone shots, which can have all kinds of side effects, most merely annoying, but some serious, and they have to have eggs removed in what is essentially a surgery. We haven’t been doing this for long enough to know how safe it is in the long term.

Lawyer: And something the article doesn’t discuss is a privacy question. Pre-implantation genetic diagnosis is now both possible and increasingly common — that means looking at the DNA of the embryo before implanting it. I don’t know that this has been done much with donated eggs, but it surely could be. Are donors giving consent for the parents to look at their DNA? Now and/or in the future? If they discover something like a disease risk, can they tell the donor? Should they? Must they? Ideally all this would be discussed ahead of time but right now I can’t imagine that it is, as a general practice.

Nurse: It’s interesting that the discussion over sperm donation is less intense. Sure, it’s physically easier to donate sperm, but part of the issue seems to be the long-term reflection that you have in fact parented a child, and I don’t hear much of that with sperm donors. I wonder if the mind-trick here is that an egg seems more substantial, we have fewer of them, and even that women cannot ever unknowingly mother a child naturally, unlike men.

Lawyer: I think the physical procedure is quite relevant here. Surgery and hormone shots vs, well, you know. But you’re right, that real difference — that women can’t unknowingly parent children in the natural way — seems somehow significant.

Legally, the rules can be different for the different sexes if the variation is based on REAL DIFFERENCES, not on stereotypes — so with regulation of things intensely biological, as here (at least in terms of the medical procedure involved), we’re on good footing for different rules. Though the difference in terms of it being your child out there is. . . less clearly a “real difference.” There has been a decent amount of litigation over the differences between mothers and fathers, and laws generally allow them to be treated differently in terms of parental rights when there’s some sort of dispute. It seems, however, that the difference that justifies those decisions — that it’s pretty much impossible to deny or contest maternity — would begin to evaporate in the IVF context.

The bottom line, I think, is that we need to make sure this is properly regulated. The pricing guidelines are all voluntary, and that is fine or would be fine if they were adhered to — but what really is the appropriate price? I’m tempted to say that there should be a single level of compensation, because why should I be paid 50K for undergoing a procedure identical to another woman who only gets 5K, because I was born with qualities completely out of my control that she wasn’t?

Ping-Pong Post: DNA Testing in Sports

Okay. We’ve been derelict in our duty. We’re sorry. Nurse and lawyer are tired. Moving, marriage, etc.

However. Life goes on. Especially during baseball season. NYT recently printed an article about the DNA tests that major league baseball has been asking for some some foreign (Latin American) prospects, attempting to verify that they are who they say they are (and not, say, a few years younger.) Here are a few of our thoughts on the issues that raises:

-There’s a federal law scheduled to take effect that prohibits employers from requiring DNA testing. My question is, what do we mean by required? Can it be encouraged, or suggested, or asked? Does refusing then become harmful? Is “on a consensual basis” really code for “if you know what’s good for you”?

From what I understand, all your nice euphemisms there amount to coercion, which you can’t do if you can’t require something. So encouraging or suggesting it… not so much. Asking people to voluntarily submit to it? That would be a gray area. I guess it would depend on what actually happened to people who refused.

-Privacy is an issue. Do professional athletes cede some privacy about their health by the nature of their jobs? Can we draw a line there? A team could reasonably want to know if a player has a chronic illness, but can they reasonably know if he may be prone to developing one in the future? The testsing that’s been used hasn’t sought to do this, but it certainly could. This is a classic slippery slope.

I don’t like it. I don’t like it at all. I mean, you can certainly choose not to hire people who don’t meet the physical requirements necessary to perform a certain job. Like play baseball. But an increased probability of not being able to do so several years in the future? That’s gotta be out of bounds.

-The tests aren’t used to reveal any real information at this point, except that a player is who he says he is, and his parents are his actual parents. It’s meant to prevent the sham that is sometimes used where a player “borrows” someone’s identity and birth certificate to appear younger and more marketable. There HAS to be a better way to beat that than DNA testing, right?

I tried really hard to think of a better way and… couldn’t. It’s not a problem for U.S. citizens, who are tracked from birth with social security numbers, etc. But remember what happened in the last Olympics with the Chinese gymnasts? If the government of their home country isn’t on board with the honesty thing, what CAN you do? Seriously? What? It’s not as though penalties would be particularly effective for people who don’t really have anything to lose.

-We tend to be upset by the idea that insurance companies could use genetic information against us. It feels wrong. It undercuts the purpose of health insurance, in a way– by not allowing vulnerable people to be covered appropriately. I think it would be unethical. So what happens to results of these tests? Are they used to determine parentage and then destroyed? Or are they read more closely, or kept? Hmmm. Does the privacy these athletes give up extend that far?

I guess that depends on what’s in their contracts? One would hope it would be destroyed, after being used for its intended purpose, but… we really don’t know, do we? Good quesiton, nurse!

-Genetic testing can bring unsavory information to light– the father is not the father, for instance. Should this be a concern?

I think this is really two questions. Parentage is one thing — that’s actually what they’re looking for! — and it would certainly be complicated if it was discovered that the claimed father was not the father. There are, as you imply, many possible explanations for such a finding that are not what MLB would be looking for. But if it is a voluntary test (and what that means is still open — see above), then I’d have to say surprises are fair game.

The other question revolves around medical information, and I think as long as the rules are clear, it will be fine.  We don’t look for huntington’s disease in the run-of-the-mill paternity test, so why would we do it here? I’m probably oversimplifying, but it seems entirely possible to only test for the particular relevant information. And as long as the lab involved is well-regulated, we should be okay. Right?

-Is it somehow exploitative to require this of foreign citizens but not of Americans?

Well… that’s tricky. I want to say no. Because what they’re doing is applying to work in America for an American organization. Unless they’re on the Blue Jays. heh. If the requirement were worded in such a way that what was needed was positive proof of identity… it seems fair to me on a practical level. There’s a reason for asking for it from one group and not another, and it has nothing to do with who they are, but rather what information is otherwise available. Does that make it inherently okay? No. But it doesn’t set off my BS alarm.

So we guess the answer here is, we don’t know. But please tread lightly.

g’night. We need our beauty sleep!

MJ, M.D.’s, and the coroner

Not to jump on a bandwagon, but it’s on the front page of the New York Times and the LA Times. . .So, the preliminary reports show Michael Jackson’s  death involved no trauma or foul play, and toxicology reports are pending– and in the mean time, major news outlets are reporting, the police have seized Jackson’s personal physician’s car because it could contain drugs or other evidence. Um. . . ok? How did this become a criminal investigation?

Obviously we, the public, don’t have the whole story– nor should we! I’m surprised that there’s as much on-the-record information from law enforcement, the coroner’s office, and others as there is.  (And of course, wild speculation on the blogosphere here,  here, and here, for example)

This is a line that we’ve seen toed several times recently– Brittany Spears’ hospitalization comes to mind– so I wonder, does a person’s status as a public figure ever override their right to privacy?

Ping Pong Post: Manny Being… picked apart by Nurse and Lawyer

First of all:

Dear Manny,

WHY? Why are you such an idiot? I loved you so hard. I was THERE when you hit that 500th home run. I defended you when my friends called you lazy and ugly. Not because you aren’t lazy and ugly, but because you were Manny. Now? You suck.



Also, I’m glad I never bought your Jersey. Jerk.

There are two basic legal issues to look at here.

1. What did Manny actually do wrong/ how did they catch him?

2. Can anybody sue anybody else as a result of this?

Lawyer: The answer to #1 is complicated, and interesting, I think, for Nurse to address. Manny claims that the drug was for a legitimate medical use. And everyone responding says this is highly unlikely. Which, granted, it probably is. But IF Manny were telling the truth, then he still didn’t follow the rules — MLB would require that he get a Thereputic Use Exemption — IN ADVANCE of taking the drug.

Nurse: When you are asked to take a drug screen, you are responsible for knowing any medications that you are taking which were legitimately prescribed that could show up. You are given the opportunity to disclose them and provide proof that it’s legit. I have had this opportunity when I’ve been tested for work, and I would be shocked if athletes weren’t given the same chance.

Manny used used human chorionic gonadotropin. HCG is a hormone that females make during pregnancy– it’s the hormone that a pregnancy test detects . It may be prescribed for women who are having fertility problems– that’s not a difficult leap to make. It may be occasionally prescribed for men who are having fertility problems also because it helps men produce male hormones– like testosterone, although it isn’t well studied. Do we see where this is going? We get even more suspicious noting that experts say HCG is sometimes used by steroid users coming off a course while the body’s own testosterone production is shut down.

HCG is prescribed under several brand names, and indicated for infertility in women and low levels of male hormones in men. More information is available from Micromedex, a clinical drug reference widely used and trusted.

Lawyer: According to the New York Times, he didn’t actually fail a drug test. Something in his medical records (which apparently they get to see — nurse? Thoughts?) was damning enough to trigger the suspension. And from what I understand, there was something suspicious but not sufficient in a urine sample, which led them to pull the medical records, which contained the damning entries.  Baseball lets the commissioner suspend plays for “just cause”  (note, you non-legal types, that that doesn’t mean “just because,” it means  a fair and sufficient reason.) And in fact, this has been the case for most of the high-profile suspensions that have happened in the last few years.

The long and the short of it is, Manny didn’t follow the rules.

Nurse: although the urine tests were suspicious, it was the investigation following that showed Manny was prescribed HCG, and this was the cause for his suspension, according to Bud Selig. Manny says the drug was prescribed for  a“personal health issue.” This would mean some kind of hormonal or pituitary problem, but it’s pretty suspicious. I’m wondering: if they can investigate his medical records to determine what was prescribed, can they also investigate why? If I were Manny, I would certainly disclose whatever condition made it legit, so. . . maybe not so much. Sure, it’s a gross violation of privacy to dig through someone’s medical records and do it publically, but when you sign up to play pro sports, should this be part of the package?

Lawyer: For issue # 2, I really don’t know know if anyone has real legal recourse here, though this being America, I’m sure someone will try a law suit. Some possible interessting scenearios:

The Dodgers sue Manny to recover all sorts of lost revenue — interesting especially in light of their attempts to market much more heavily to Hispanic fans.

Nurse: I foud some numbers on the WSJ: Mr. Ramirez generated roughly $7.6 million in ticket sales, parking, food, drink and merchandise for the Dodgers, and average attendance jumped after his arrival. The Dodgers sold 14,000 Ramirez T-shirts, 7,000 dreadlock wigs and 500 jerseys. When he signed a new two-year, $45 million contract in March, the team spent an estimated $2 million on advertising for the season. The campaign included splashing his image onto billboards. A Dodgers spokeswoman says they will be replacing those billboard images soon.

Lawyer: Nice one, Nurse. That’s exactly the sort of thing I could imagine them suing over.

Other possibilities: Fans sue Manny or the Dodgers

Or, as Gabe Feldman suggests (is he joking or not?)  on his Sports Law Blog, fantasy baseball types sue Manny because now their fantasy teams are in the crapper. (More about that here.)

I seriously don’t know how any of this would work, and I probably never will, because sports law is not exactly on my list of must-take classes.

But I do know this: the way that tort law works in this country, it’s meant to more or less allow money-related issues and perceived unfairness to work themselves out. There’s been a lot of debate about how to enforce the drug policy in baseball and many other arenas (zero-tolerance is desirable in some ways, but also flawed, not least because the testing is imperfect.) If players could be sued for big bucks for violating the drug policy, isn’t that likely to be more effective than simply suspending them for a few games? MLB doesn’t have to make new draconian rules. Our existing legal system, applied to this situation, could get it to right itself.

One final note: though I still kind of can’t believe there’s a whole blog devoted to the rules and legal issues of fantasy sports, the folks at SportsJudge did bring up an interesting point: there is a clause in the standard player contract that basically says the player has to behave. It doesn’t specify what constitutes behaving in terms that are really any more specific than that. And if he doesn’t, the club can boot him. Does this count?

It’s all happening!

Well, I guess we weren’t the only ones who read the “HITECH” part of the stimulus bill. Companies have kicked their marketing machines into gear to try to cash in on this whole thing.

WalMart wants to sell your doctor a package of Dell computers, eClinicalWorks software, training, and support.  Which is interesting. On the one hand, I’m not sure I want anyone to buy the system that tracks my sensitive information at Sam’s Club. Especially given that no attention has been given, at least in this initial coverage, to security.

On the other hand, if you really support the adoption of this stuff, this is probably the way to get it out there. Can you get any more mainstream than WalMart? And if they distribute it efficiently enough  make it cheap enough that the rebates from the stimulus bill will actually cover a decent portion of it, goshdarnit, some doctors might actually use it.  So the jury’s still out — might work, but please start telling us how you’re going to make this safe!

Another recent PR move comes, oddly, from Apple. They seem to be trying to convince medical practices that Macs, being so convenient, easy to use, and, well, shiny, are best because they won’t have to waste time on training, and patients don’t mind having them in the room. Apple: please don’t discourage companies from training the health care professionals. With all the issues involved, there is no such thing as a plug-and-play EHR system.

Also, the example they used was from Canada.  Seems that there are no Mac-friendly EHR suites approved in the US? eClinicalWorks, the WalMart pick, is available in (limited) mobile version for the iPhone but not for the Blackberry. But you can only run it on a Mac if you use Boot Camp. Hmmm. What’s going on?

Don’t get me wrong. I love Macs. I even have the little white apple sticker on my car.  But this “news item” seems a little misguided to me. Guess they weren’t really counting on much attention there anyway, since all eyes are on the unbelievably tiny new iPod.

And neither story even mentions security! Like, not even to say “of course, all of this will be secure.” The only mention of it I found was as a vague excuse for why the iPhone app for eClinicalWorks isn’t more fully-featured.

America: the commerce machine is on. Don’t get swept away.

Ping-Pong Post: Electronic Health Records

The stimulus bill includes an extensive title on Health Information Technology. And your very own “Lawyer” read the entire Title. (Okay, fine. She skipped the section on grants and loans. But she read the rest of it.)  Let’s take a look at the good, the bad, and the ugly.

Lawyer: If we could absolutely guarantee total privacy of these records, (granted, we can’t,) would there be objections to the system? There are clearly many potential benefits — both for any individual patient’s care (diagnosing, preventing duplicate tests, avoiding drug conflicts, more please, nurse?) but are there any potential pitfalls from a healthcare standpoint?

Nurse: There is the potential for a provider to be lazy or for a tricky diagnosis to be missed if we assume that the record is accurate, or we are influenced by what someone else has entered. Also I would like to think that knowledge of previous conditions or things like drug abuse would only be used in a patient’s best interest, but some healthcare providers judge and discriminate inappropriately. It might be easier to do this with electronic medical records.

Lawyer: Privacy is obviously a huge concern. Of the 60-some page section of the bill devoted to this program, 20-some are devoted exclusively to the privacy and security measures being undertaken, including the appointment of a point person whose entire job is to oversee the development, testing, and approval of security measures for this thing. What are the practical concerns about security? I mean, yes, there is the icky feeling of violation, and that is legitimate. But beyond that, what should we fear?
What else? What are we *actually* afraid of here?

Nurse: When people rely on private, employer-based insurance, they may be denied coverage for certain conditions, or they may face discrimination.

Lawyer: So I guess the question is who is going to have access to what parts of these records. The bill doesn’t specify – it only specifies which entities and various appointed people will set these standards and develop and assess the technologies to carry them out.

Nurse: There are already more stringent privacy laws attached to diagnoses like HIV. How will this be carried forward? How is that protection approached in the context of a comprehensive and accessible electronic record?

Lawyer: Another really good question. And I don’t know – I don’t know how it works now, either. I do know that the law specifies the use of limited data sets, with a minimum-necessary standard – so in, say, a public health or research setting, your name, SSN, etc, would never be attached to your sensitive diagnoses.

Nurse: I think it’s possible, also, that patients would delay care or avoid medical situations if they didn’t want something in their record of if they knew something was there.

Lawyer: The authors of the bill are definitely aware of that concern – but I’m not sure they have a good solution. They even mention that concern specifically in the bill and specify the need for educational efforts to reduce that sort of behavior.

On a related note, one of the provisions that’s been catching a lot of attention is that they’re attempting to establish an electronic health record for every person in the United States by 2014. It looks like (though I’m not entirely sure how to interpret this language) people can request that their information not be disclosed, as long as the request isn’t surrounding the need for payment for a service. (You can’t opt out of having the information about what procedure was performed that they owe money on go to your insurance carrier unless you’re paying for it out of pocket.) And even then, it will be a “minimum necessary” disclosure. Which I guess makes sense.

Nurse: What if information is lost or stolen, what are the backups in place? There have been several recent cases of hospitalized celebrities having their privacy breeched. I see potential for that kind of abuse here.

Lawyer: The way this bill is written, it’s already assuming that we will come up with security provisions that are sufficient. The bill doesn’t specify what the safeguards will be – it discusses how they will be evaluated and adopted. It also discusses the penalties for entities that allow any sort of security breech. In other words, we’re no longer asking whether this might be feasible. We’re assuming it will be, though we don’t yet have the measures in place or the technologies developed. Is this warranted? TJ Maxx might’ve been broken into, but online baking remains safe and secure. So my feeling is, it should be fine, as long as sufficient care is taken, and it’s certainly written into the bill.

Nurse: The perfect is the enemy of the good, and it’s not perfect now, so we do stand to lose by getting bogged down. Where is the dividing line between useful improvements and endless legal tinkering? There are MANY advantages:

-It would potentially save a lot of money, both in unecessary tests and treatments and in provider hours used, to have medical histories accessible even for patients who cannot tell us or don’t know their own history. Even in my limited clinical experience, I’ve seen a number of criticallly ill patients without a good history, and this undeniably affects our ability to give them the best care.

-It could potentially be life-saving to have pertinent medical info at hand when a patient arrives in an emergency situation—knowing an allergy or a condition or a blood type, for example.

-It would cut down on unintentional errors and intentional abuse that occurs when a single patient sees multiple doctors and doesn’t mention all medications and treatments being used. Allowing pharmacies and physicians to access an entire record would absolutely help to avoid what are now strikingly common errors.

-Within a hospital, even, it makes a difference. I’ve worked at places where different parts of the record and orders systems were computerized, and there are far fewer mistakes and generally less wasted time when the paper steps are removed all together.

-Patients can be greatly empowered by having access to their own health information. It would also perhaps help to promote accountability on the part of providers.

Lawyer: Yeah! Way to go, Nurse. I would like to point out that the bill dictates the composition of the HIT policy committee, and it specifies two health care providers, one of which must be a physician. It doesn’t say anything about the other, but they’d better pick a NURSE! Also, think the office of the National Coordinator will need a legal intern in the summer of 2010? Cause I might be available…