How Private is Private? Is Google a covered entity?

Back in 1996, the Health Insurance Portability and Accountability Act (HIPAA) was enacted by Congress for the purposes of ensuring continuity of healthcare benefits for workers changing or losing their jobs (Title 1) and to establish national standards (Title 2) for electronic health care transactions, maintenance of privacy about so-called protected health information (PHI) and security of that information maintained in electronic repositories (e.g. hospital information systems and other data bases).

Since the actual implementation of the Privacy and Security Rules in 2003, there have been considerable efforts on the part of healthcare organizations (providers, health plans and so-called healthcare clearing houses) to develop policies and procedures which adhere to federal law while still carrying out patient care effectively as well as managing clinical research productively. Of course, nothing is perfect and there have been a plethora of papers and media articles on the barriers to patient care (Gross 2007) and to important large population based clinical research (Armstrong, Kline-Rogers et al. 2005; Wolf and Bennett 2005; Wilson 2006). Further, the security of PHI is not so great either (Freudenheim and Pear 2006).

Therefore, health insurance might be portable for some workers, but PHI is not!

With all the recent hoopla about Microsoft wanting to purchase, somewhat hostilely, Yahoo in order to “corner” the market on search engines, it might have been easy to overlook 10 second sound bites on the morning radio news, or the little technology tidbit in the New York Times (Lohr 2008) which was NOT on the front page.

So it seems that Google actually will scoop Microsoft in implementing a web based interface with a major healthcare system, in this case the Cleveland Clinic with its some 100,000 patients. The deal is, if one has a Google e-mail account, one can use the same sign-in and password to access and transmit one’s medical records. Apparently, the pilot phase will involve only some “innocuous” data such as allergies and prescription records. However, prescription records can certainly allow inferences about underlying health conditions for specific patients which, if leaked, could have problematic consequences. Funny how Google mail accounts are encryption proof (Stone 2007) to corporate electronic security walls. Does that provide some clues as to how undone PHI privacy could become?

And what about HIPAA? There is some debate about whether Google could be considered a healthcare clearing house or other entity which information repositories containing people’s PHI would be considered protected and would have an obligation to protect under current federal regulations. The World Privacy Forum (Gellman 2008) thinks not.

Other dicey questions: will Google patients be subject to advertising spam or other intrusive advertisement adduced from their prescription lists? What guarantees that the “client” (read patient lists) won’t be sold to Pharma companies as yet another means of developing data bases about physician prescribing patterns? Who is going to regulate these issues? Google is a great search engine—I use it all the time! But I’m not sure I want to use it to manage my healthcare information. I’d rather continue to keep it on my PDA!


Armstrong, D., E. Kline-Rogers, et al. (2005). "Potential impact of the HIPAA privacy rule on data collection in a registry of patients with acute coronary syndrome." Archives of Internal Medicine 165(10): 1125-1129.
Freudenheim, M. and R. Pear (2006). Health hazard: computers spilling your history. New York times. New York.
Gellman, R. (2008). Personal health records: why many PHRs threaten privacy, The World Privacy Forum.
Gross, J. (2007). Keeping patients' details private, even from kin. New York Times. New York.
Lohr, S. (2008). Google Health begins its preseason at Cleveland Clinic. New York Times. New York.
Stone, B. (2007). Firms fret as office e-mail jumps security walls. New York Times. New York.
Wilson, J. F. (2006). "Health insurance portability and accountability act privacy rule causes ongoing concerns among clinicians and researchers." Annals of Internal Medicine 145(4): 313-316.
Wolf, M. S. and C. L. Bennett (2005). "Local perspective of the impact of the HIPAA privacy rule on research." Cancer 106(2): 474-479.

US healthcare: we spend and spend, but....

This week the Department of Health and Human Services released the news that US healthcare spending broke the $2 trillion mark in 2006. Yes, you read that right: TWO TRILLION DOLLARS. This is despite the fact that the annual increase in healthcare costs has actually slowed down a bit in the past few years. (Read more at the NYT here.)

What do we get for this enormous outlay? Well, not so much as you might think, and not as much (in terms of outcomes) as lots of other countries that spend less.

In 2007, the Commonwealth Fund surveyed 12,000 people in 7 countries: Australia, Canada, Germany, the Netherlands, New Zealand, the UK, and the US. (You can find the abstract in Health Affairs, here.) Despite spending nearly double what some of the other countries spend per capita on healthcare, US respondents were more likely to report experiencing medical errors; going without needed care because they can't afford it; and to say that the healthcare system needs to be completely rebuilt. We--along with our neighbors to the north--are also least likely to be able to get a same-day appointment when we're sick, and more likely to show up in the ER because we don't have an alternative.

Consider just this one fact: 32% of Americans surveyed who had two or more chronic conditions said that they'd experienced a medical error in the prior 2 years. Keep in mind that these are just the errors patients know about!

So, it being election time (as if we could forget!), let's see if we can't get the candidates to say more than just "Healthcare is broken, and I'm gonna fix it." Covering more people is an excellent start--but just a start. Among other items on the healthcare to-do list: figure out how to improve quality, how to re-value primary care, and how to help people be more effective self-advocates.

Happy New Year: A Celebration of Hope

A very Happy New Year to all of our readers from all of us here at the Women's Bioethics Blog -- I love ringing in the new year, it always hold so much promise. For what can we hope to make it a healthier, more ethical New Year? A few things come to mind:

- Transparency -- I just learned this phrase I had not heard before: "Sunlight is the best disinfectant" and for just about every profession, from academia to health care to the justice system, the metaphor holds true.

- Accountability -- a corollary to the above concept -- as a fellow blogger over at the Healthcare blog notes: "The main value of transparency is not necessarily to enable easier consumer choice or to give a hospital a competitive edge. It is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care."

- A step towards healing our broken health care system in the US. (as Art notes in his editorial cited below).

-- Tell us, what do you hope for in 2008?

Ten Biggest Health Stories of 2007 (from Alternet)

Okay, I promise this is my last 'top ten' post (at least for today and mostly likely for 2007 -- Can you tell I love these lists?). For the next few days, I will be en route to Indonesia and East Timor, so you won't hear much from me, but I do hope to do some blogging in Bali!

From criminal health care to outrageous diet plans, these are AlterNet's most-read health stories of the year:

10. Even Republicans Hate Our Health Care System

9. Are You One of the Shrinking Americans?

8. I'll Have My Cosmetics with a Side of Infertility, Please

7. The Toxic Chemistry of Everyday Products

6. Private Health Insurance Is Not the Answer

5. The Stone Age Diet: Why I Eat Like a Caveman

4. Controversial Michael Moore Flick 'Sicko' Will Compare U.S. Health Care With Cuba's

3. The Frightening New Normalcy of Hating Your Body

2. You Call Yourself a Progressive -- But You Still Eat Meat?

1. Michael Moore Rips Wolf Blitzer on CNN: "Why Don't You Tell the American People the Truth" [VIDEO]

For links to all the above stories, click here.

Wishing you all a happy, joyous, and abundant 2008!

We're Number Two? The State of US Healthcare

According an article in Scientific American this week, Canada has good or better health care than the U.S. despite spending half what the U.S. does on health care:

"Whether it is American senior citizens driving into Canada in order to buy cheap prescription drugs or Canadians coming to the U.S. for surgery in order to avoid long wait times, the relative merits of these two nations' health care systems are often cast in terms of anecdotes. Both systems are beset by ballooning costs and, especially with a presidential election on the horizon, calls for reform, but a recent study could put ammunition in the hands of people who believe it is time the U.S. ceased to be the only developed nation without universal health coverage.

Gordon H. Guyatt, a professor of epidemiology and biostatistics at McMaster University in Hamilton, Ontario, who coined the term "evidence-based medicine," collaborated with 16 of his colleagues in an exhaustive survey of existing studies on the outcomes of various medical procedures in both the U.S. and Canada. Their work appears in the inaugural issue of the new Canadian journal Open Medicine, and comes at a time when many in Canada are debating whether or not to move that country's single-payer system toward for-profit delivery of care. The ultimate conclusion of the study is that the Canadian medical system is as good as the U.S. version, at least when measured by a single metric—the rate at which patients in either system died.

"Other people knew that Canadians live two to two and a half years longer than Americans," says Steffie Woolhandler, an author on the paper and an associate professor of medicine at Harvard Medical School, citing a phenomenon that many attribute to differences in lifestyle between the two countries. "But what was not known was once you got sick, was the quality of care equivalent in the two countries."

To read, click here.