Cure v. Palliation
For those that practice in emergency medicine or work in ERs, we share a common bond of enjoying both the excitement and diversity of medical conditions that find there way in. There is nothing as satisfying and rewarding as participating in a medical or trauma resuscitation where there is a good outcome. And there is nothing so important as helping family and friends deal with the loss of a loved one due to a medical or surgical emergency.
Unfortunately, the realities of emergency medicine practice is not dealing with true emergency, but rather acute episodes of chronic illnesses, the failings and lack of primary care, and those suffering from psychiatric and other social ills. We find ourselves many times not treating actual diseases or disease states, but rather treating symptoms, expectations, desires, and risk-aversive beliefs. We are educated and trained to treat disease, and yet are practice, many times, is palliation.
Several weeks ago I was treating a ninty year old Thai woman who was on Methadone. She was being admitted to the hospitalist service because of a significant pneumonia and hypoxia. She was on Methadone because she smoked opium in Thailand prior to her immigration to the US more than twenty years ago.
She received an antibiotic and oxygen, and she also required a significant amount of narcotics because of her chronic narcotic dependency. I was struck by the fact that the disease pneumonia would be treated successfully with the antibiotic. The oxygen would temporize the hypoxia that she would be experiencing while undergoing treatment for the pneumonia. And the hospital–supplied Methadone would ameliorate the narcotic withdrawal during the hospitalization. The score for this admission was two cures and one palliation.
Methadone, regardless of how the patient comes to be prescribed it, is a palliation. It is a palliation either for a disease state that is terminal (death is expected soon) or deemed non–curative (the time of death is indeterminate). Non–curative comes in two flavors: no cure is known or the cure is deemed too costly in comparison to chronic palliation. We as a society accept palliation where there is no cure or where there has been a valuation on the cost of cure versus palliation.
Health Information Exchange Palliation
If health information (HI) can be conceptualized as various currencies—then these currencies in the US exists in innumerable incompatible physical forms (paper and digital). How these currencies are characterized by the particular holders of these currencies is also inconsistent across the country. Because vendors and customers in our HI economy have been allowed free choice, based upon their own valuations and needs, these incompatibilites and inconsistencies are myriad. This is the argument for health information exchanges (HIE).
Extending the currencies exchange concept for HI, the equivalent of regional and national banking system is contemplated to effect this massive currencies exchange. This is the argument for regional health information organizations (RHIO) as part of the national health information network (NHIN). To effect a true single currency in HI, that may be utilized across the country, requires a high degree of participation by all holders of particular currencies in the regional and national HI banking system.
Changing from an economic to a medical metaphor, the need to effect regional and national HI exchanges is a symptom of the disease process/state. The disease is the incompatibilites and inconsistencies throughout the HI industry. The disease is carried by HI vendors and customers and caused by parochial or enterprise valuations, concerns, and legacy installations. Symptomatic treatment without addressing a cure is palliation. Here the palliation is the exchange—and the questions should be is there no known cure and has there been a valuation on the cure versus palliative costs? If there has been a valuation of cost, then who has performed this valuation and how has the potential financial–biases been addressed? Are those responsible for the disease state the best (or only) judge on the palliative or curative options?
In addition to the need for a high degree of participation in the palliative option, it is implicit that there will need to be a significant overhaul of the institution–specific infrastructures creating and maintaining the current disease state of incompatibilites and inconsistencies. This is separate and distinct from the institution–specific infrastructures, processes, and practices that will need to be installed to effect the palliative option (participate in HIE). Add to this the annual participatory cost (beyond governmental seed–funding) needed to effect the palliation indefinitely. Are we not creating the HI equivalent of a national Methadone program? Are we to believe that the cost of creating, installing, and maintaining indefinitely regional and national HIE is less costly then addressing curative measures?
Health Information Exchange Intervention
During my trauma rotations in residency, it was common to see a t–shirt worn by members of the trauma service bearing a picture of Charles Darwin with writing, “Darwin is disappointed with our work.” Now that certainly represents dark humor, often seen in training institution (and is no longer acceptable), but I’m reminded of that t–shirt when I consider what HIE/RHIO/NHIN is all about. Darwinism, so entrenched in our society, is being violated in that parochial installations of HI technologies are so dated, so incomplete, and so incompatible and instead of allowing them to die we are going to divert millions (and I suspect long term billions) of dollars from patient care to indefinitely resuscitate those of the HI species that should succumb to natural selection.
Or is it like our recent financial institutions crisis, where our national interest and survival required us to violate our capitalistic heritage and save those that cost us so much? But the distinction here is that the financial institutions are paying the governmental bailout back—and where they can’t, there is no indefinite palliation or veneer of addiction. No industry has been created, with its commensurate inertia, to provide the palliation or maintain the addicted state.
We seem to be caught in a perpetual cycle where the industry responsible for the creation of the disease state is seeking indefinite funding to maintain the disease state, albeit under palliative care. Is there no intervention? Is there no definite cure? And perhaps more troubling is the consideration that curative measures will be forestalled or unimplemented in anticipation and reliance upon the cost of palliative measures broadly borne. How much will not be done now because of the belief in another day and someone else’s dollar?
As a physician I understand the need for a complete set of HI available for each patient at the time of service. Cure is desired and palliation may be the only alternative—but at this stage in the HIE development it seems a decision arrived at because of industrial inertia and not because of rational deliberation and consideration of the long–term final costs and consequences.
