Health IT

HEALTH IT: The Not-So-Private View from HHS

Joanne Kenen — Thu, 08 May 2008 18:10:00 -0400

Earlier this week we posted our interview about the future of health IT with Carol Diamond of the Markle Foundation. (Part one, and part two). Today we'd like to point you to The Hill 's interview with Health and Human Services Secretary Mike Leavitt on the same topic.

Two points struck us. First, neither the article nor the full Leavitt transcript mentions the word "privacy"—a big issue both for policymakers and for the public who keep reading about nosy hospital staff, researchers who do sloppy things like leave laptops with patient records in the car, and thieves who steal credit card numbers and other financial identity information from medical records. Not insurmountable but essential if we're going to get the country on board with health IT. Second, Leavitt really depicted the health IT challenge primarily as a technology question involving interoperability (letting different computer systems talk to each other) while Markle's Connecting for Health program and conversations with some other experts have made us think about a far broader range of policy challenges that won't be solved only by the computer geeks.

We did like that Leavitt pointed out that the electronic medical records (with appropriate privacy safeguards) won't just improve care for individual patients. Properly designed, they will provide a huge data pool for researchers to track public health threats, emerging trends or epidemics, drug side effects and the like as well as do research into what treatments work best for patients. But first we've got to get there. Leavitt sounds optimistic, but we've heard that health IT is just around corner for some time. Let's hope he's right sooner rather than later.

HEALTH IT: Markle's Carol Diamond on Making the Connections (Part 2)

Health Policy — Wed, 07 May 2008 15:44:00 -0400

Yesterday we posted the first part of our conversation with Carol Diamond, M.D., M.P.H., the Managing Director of the Health Program at the Markle Foundation in New York. She spoke about the potential of health information technology to improve the quality and restrain the costs of our care, as well as the research benefits. Today, in the second and final installment, she discusses some of the barriers to bringing 21st century tools to a paper-based health system, and the path to overcome them.

Q: What are the challenges to a national health information technology system?

A: There can't be one information technology "system." We start with a vast, highly fragmented and very diverse health care delivery model that is not centrally controlled or run. The only practical way forward is to acknowledge existing networks, and let them grow incrementally under a basic, common sense set of policies and standards. That's how the Internet grew.

The health care sector has a set of unique challenges that need to be overcome—and some have nothing to do with technology.

The first critical challenge is trust. Without it, patients and physicians will not be willing to use new technologies due to fear of privacy breach or the misuse of personal health information. Broad use of information technology, and the transformation it can bring to health care, will only occur with widespread participation and trust from consumers. Consumer trust will be dependent upon their willingness to participate and their confidence that their information will be protected. This assurance can only be established if we have strong information policies that guide the development and use of new electronic tools—something we in Connecting for Health consider part of a "Common Framework."

A second challenge is financial. In the current model, the providers who invest in IT contribute to the improvements in care, but they do not always directly reap the benefits. Current payment models are often heavily based on paying for visits or procedures and therefore do not establish the necessary incentives for investing in information technologies that will potentially improve quality or reduce unnecessary or repeated services. This misalignment of incentives means that many providers are reluctant to invest in these tools. To create incentives for information sharing, we must focus on a new approach that rewards quality of care and not just the quantity of care.

Clearly, these are interrelated. An environment that has the necessary policies to assure that personal health information is kept secure and protected will also create opportunities for new business models that reward innovation and creative uses of technology that can radically improve the quality and safety of care.

Q. How has Markle attempted to reduce these barriers?

A: When we started Connecting for Health we knew that protecting privacy and security was critical. We made this a cornerstone of our efforts and set out to find areas of agreement so that we could articulate a practical way forward agreed to by many diverse sectors within health care.

Current public concerns about identity theft and the broader dangers of breaches could lead to inadequate participation in HIT, which in turn would be a setback to our window of opportunity to transform health care. To accelerate progress, it's essential to form a common set of rules for sharing information electronically while keeping it private and secure. For example, when you look at something like the ATM network, you probably don't consider the policies and practices that make it secure and broadly implemented. Yet, ATMs do operate under some common policies and technologies that have evolved to enable a network through which vast sums of money and transactions pass each day.

To support a similar evolution, we anticipate and deal with questions like: What protections must be in place for information to be shared with authorized parties? How should access to the information be provided electronically and what safeguards must be in place? What are the rules that apply to the shared information and what measures must be in place in the event of a breach? Our balanced approach to addressing these issues has allowed us to find areas of broad agreement on many challenging issues that have been divisive or difficult to tackle in the past.

The Connecting for Health Common Framework is a set of policy and technical standards for information sharing. These standards highlight the importance of considering both policy and technology choices and decisions upfront in a coordinated way. All too often we see technology choices being made without policies or policies being made without the technology to support them. When either area is addressed late in the game, either the technology needs to be retrofitted to accommodate the policies or the policies are weakened due to the inability to implement them in existing technologies. Rather, at the highest level, the Connecting for Health Common Framework contemplates three key attributes together:

Core Privacy Principles—These principles define a set of desired privacy policies to ensure personal health information is protected. Our approach to these principles is rooted in the U.S. Fair Information Practices, which were established more than three decades ago.
Sound Network Design—HIT must be developed in a way that adopts sound network design characteristics that enable interoperability and safeguard information. The network should be distributed and decentralized to minimize the risks of large-scale privacy spills.
Accountability and Oversight Mechanisms—Information policies cannot be meaningful unless they are fully implemented and adhered to. Implementation of health IT initiatives should include the appropriate oversight and accountability levers needed to assure that the entire set of attributes and information safeguards are achieved and adhered to.

These three high-level attributes are meant to be broadly applicable. We have found them to be an invaluable framework for doing the detailed work of specifying exactly what is needed to protect privacy and security. Over the last two years we have created very detailed specifications for two HIT applications in particular, health information exchange (HIE) efforts across communities of providers and additionally, for the personal health services offered directly to consumers—that have captured the attention of government agencies, technology vendors, and global internet brands.

When it comes to Health Information Exchange, communities or state-based efforts have used the Common Framework as a starting point for planning their own HIT initiatives. For many, the Common Framework provides assurance that the hard work of identifying key issues has already been done—and it has been vetted and tested by leaders in the field. We are told time and time again that the Framework greatly helps organizations or states to create their own roadmaps for HIT initiatives and facilitates decision-making across diverse groups of people needed to move these initiatives forward.

When it comes to using the Connecting for Health Common Framework for establishing a way to navigate the new world of personal health services, our collective efforts with many organizations to create the detailed and necessary policies and practices has been ground-breaking. Our work has enabled traditional health care providers and global Internet companies to work together in spite of an uneven regulatory and legal environment to agree on a set of 15 specific policies and practice areas to protect privacy and security.

While there are significant barriers and challenges ahead, there is also a tremendous amount of energy, enthusiasm and commitment. We have been amazed at the level of dedication and earnest hard work that has gone into working through some of these challenges in our Connecting for Health efforts. I think more so today than ever before people recognize that health IT can only take hold if we establish trust that is rooted in reasonable and practical standards and policy-setting. That's what it's going to take to help improve care and help people live healthier lives.

HEALTH IT: Calling Sherlock Holmes

Joanne Kenen — Tue, 06 May 2008 21:01:00 -0400

We're suckers for medical mysteries like the one in today's Washington Post health section headlined "Five Doctors, Stumped." Today's medical whodunit (or more accurately who-didn't-do-it) was about the misdiagnosis of a woman named Bettie Munro, thought to have Parkinson's disease. Munro did not have Parkinson's. Instead, an upset stomach among other things had changed how her aging body was absorbing lithium, creating a toxic condition. One sentence near the end of the story particularly struck us, "One physician said he thought another had checked her (lithium) level, so he didn't bother." It made us think about the interview we just posted with Dr. Carol Diamond, an expert on health information technology at the Markle Foundation. We don't believe (and Diamond doesn't assert) that health IT will stop every medical mistake, avoid every misdiagnosis, create a perfect world of health and harmony. But we can't help wondering: if the five doctors caring for Bettie Munro—a psychiatrist, a neurologist, her internist, a gastroenterologist and her husband, a retired obstetrician—had all been reading one computerized medical record, with all her medications, all her lab work, all her symptoms, all their (legible) notes, wouldn't there have been a pretty decent chance that one of them would have figured out what was wrong? Or what needed to be done? She and her family would have suffered less. And the health care system would have saved $100,000 in tests, medicines and unnecessary hospitalizations.

HEALTH IT: Markle's Carol Diamond on Making the Connections (Part 1)

Health Policy — Tue, 06 May 2008 15:43:00 -0400

Many Washington, D.C. policymakers (including the presidential candidates) talk about the need for more health information technology. Everyone seems to agree that health IT will improve quality and can help control costs. For instance, RAND has estimated that greater use of health IT will yield an annual efficiency savings of $77 billion over 15 years. A study in JAMA showed that when doctors use computers to order medications, preventable errors drop by as much as 55 percent. Another study in the Annals of Internal Medicine showed 12 to 20 percent improvements in compliance with physician guidelines and other benefits. Despite all this agreement, we haven't quite figured out how to get from here to there. So we asked Carol Diamond, M.D., M.P.H., the Managing Director of the Health Program at the Markle Foundation in New York, to share her insight into how we can overcome the policy and technical challenges and bring 21st century tools to our paper-based health system.

Q: Health IT can be confusing. If you were at a cocktail party, how would you describe what you do?

A: Markle's work centers on the idea that emerging information and communications technologies can improve peoples' lives. That includes the health arena. We are working to accelerate the rate at which modern information technology enables consumers, and the health system that supports them, to improve health and health care.

Health lags behind other sectors in taking advantage of 21st century information tools. We know there are great benefits to modernizing the way health information is collected, shared, and analyzed. Our work takes on the challenges that have so far prevented the widespread adoption of these tools. When we can overcome these challenges, and accurate information is available to consumers and those who care for them, the result will be better and safer health care.

Q: What is Connecting for Health?

A: Connecting for Health (http://www.connectingforhealth.org/) is a public-private initiative established by Markle in 2002 that brings together a diverse group of health, policy, and technology leaders. Though each person brings a particular perspective, together, we share a single purpose: to improve health and health care for consumers by advancing use of health information technologies (HIT). Over the years, more than 100 organizations have been participating in Connecting for Health, including consumer groups, clinicians, hospitals, government entities, privacy advocates, technologists, and businesses. Together we have worked to address and define the issues that can accelerate the use of HIT.

Connecting for Health brings together leaders working toward making vital health information available when and where it's needed in a private and secure manner so the best possible care can be provided.

Connecting for Health is led and operated by the Markle Foundation and has received additional financial support from the Robert Wood Johnson Foundation. I've been honored to serve as Chair of Connecting for Health since 2002.

Q: Why is information technology so important to improving our health care system?

A: Despite unprecedented levels of health care spending and advances in medical technology, American health care remains inefficient and ineffective in many ways. National spending is 16 percent of GDP, which is much higher than other industrialized countries. But on the basis of quality, the United States is ranked #37 by the World Health Organization.. And according to the Institute of Medicine, almost 100,000 Americans die every year from medical errors in hospitals. That's the equivalent of a Boeing 747 crashing every two or three days.

We know, today, that technology can improve efficiency, quality, and safety. By improving communication and care coordination among providers, implementing tools that offer decision support for clinicians, and enabling patients to access their health information when needed, patient safety could be enhanced while waste and inefficiencies in the system could be reduced. To illustrate, RAND has measured that if most hospitals and doctors' offices adopted health IT, the potential efficiency savings for both inpatient and outpatient care could average over $77 billion per year.

Look around to other sectors from banking to travel services to e-commerce. They are "networked." By tapping into information networks, you can pay bills, book flights, pay a stranger on eBay, etc. The U.S. health care system has yet to be transformed in similar ways. We must figure out how to share health information according to the needs and wishes of each individual so that they can receive the best possible health care and, at the same time, take great care to protect their privacy and the security of their health information.

Q. Can you give a specific example of how technology would positively affect care?

A: There are many. The complex world of modern medicine has become nearly impossible to navigate without the assistance of electronic systems. Simple advances in our ability to manage medications could have a profound impact on quality and safety. For starters, simply having a complete and accurate accounting of medications that people are taking can be an enormous step forward in terms of avoiding dangerous drug interactions. Information—such as whether you are allergic to a medication—can save your life. If that information is available, it can help those who care for you give you safer, more effective treatment and care.

But it does not stop at improving care for individual patients. It's also about learning more quickly what works and what doesn't work for whole groups of patients. Compared to paper, electronic health information can radically accelerate our ability to understand in a timely way what treatments work best, and which may present unacceptable risks. It can help us monitor the spread of disease outbreaks that may represent pubic health concerns. Information is critical to improving quality and safety for many people.

Consumers also need access to this critical information. Never have people been more engaged in using information tools to understand their own health or the health of their loved ones. Once people have access to their own information, they can take advantage of new information services to help them better manage their own health and to become better partners in their health care with their physicians and other caregivers. While simply searching for information about health conditions is the most popular reason for people to use the Internet in health, other forms of social media and social networking are taking hold. These include online forums, blogs, and live chat rooms. In many online communities, consumers are sharing their own information about their diseases, treatments and health experiences. These new streams of data, innovative tools and patient communities pave the way for new patient roles in health care research, decision-making, and information sharing.

(Check back tomorrow as Dr. Diamond talks about the challenges—and the progress.)

HEALTH IT: Crime and Punishment (Please)

Joanne Kenen — Wed, 30 Apr 2008 19:18:00 -0400

The Wall Street Journal had a great piece and blog item yesterday about Health IT and privacy breaches — we would have blogged about it then had we not, coincidentally, been out much of the day with some other think-tankers and foundation folks educating ourselves about that very topic. Among other things, the Journal article made the key point that privacy breaches are rarely prosecuted. That's not the right way to build public confidence in electronic health records.

Some 35,000 reports of privacy violations have been reported to the Department of Health and Human Services under HIPAA (Health Insurance Portability and Accountabilty Act) since 2003, but not a single civil fine has been levied, WSJ reported. HHS says several hundred reports of violations have been referred to the Department of Justice for criminal prosecution; about 200 cases have been filed although it's not clear how many of them were under HIPAA.

So we were pleased to see the LA Times report today (Charlie Ornstein's done a lot of good work on this whole phenomenon of Hollywood sneaky peeky) that an alleged celebrity snoop at UCLA Medical Center had been indicted for allegedly selling information from medical records of celebrities to the media (apparently the National Enquirer).

The paper reported that Lawanda Jackson, 49, could face up to 10 years in prison if convicted of the charge of obtaining individually identifiable health information for commercial advantage. The paper had earlier reported that Jackson had allegedly pried into the private medical records of California First Lady Maria Shriver, Farrah Fawcett, and 60 others. In an April 8 interview with the newspaper, Jackson denied that she had leaked the information or otherwise profited from it.

Hospitals can (and should) take multiple steps to make records more secure; for instance, walling off parts of the computerized records so that people can access only what they need to know. But the feds (or state governments) have responsibilities too. Getting electronic records right, from technical, economic, and privacy standpoints, is hard enough. If all the public hears about is breach after breach, snooping, spying, and carelessness (medical records left on a laptop in someone's car trunk...) they aren't going to buy into Health IT. And we need them to; Health IT may not save as much as quickly politicians are promising but it is essential for quality, for coordinated care, for efficiency and for research. So when there's a crime, let's see some punishment.

QUALITY: Learning Health IT Lessons From the VA

Health Policy — Wed, 23 Apr 2008 15:30:00 -0400

New Health Dialogue is pleased to welcome Phillip Longman, a Schwartz Senior Fellow at New America Foundation, to share his expertise on the health IT systems of the Veterans Health Administration.

A visit to almost any VA medical center these days demonstrates how the system has overcome its bad old days to become a model of 21st century health care—if only we don't undo the very changes that got it there. At the VA medical center in Durham, North Carolina, for example, a computer-driven robot fills prescriptions, automatically putting the right pills, in the right number, in the right bottles, with the right labels and barcodes, based on orders doctors enter digitally into the VA's world-class electronic health record software.

Then, two robots I also got to know, affectionately called Tug 1 and Tug 2, cruise the hospital corridors delivering meds to nursing stations. Along with many other benefits, these technologies have reduced wait to have a prescription filled to just 28 minutes and virtually eliminated dispensing errors. Before nurses can dispense the meds, they must scan the bottle, scan themselves and scan the patient so the computer system can make sure it's the right patient, the right time, the right med, and so forth. This is no small deal. Patients in non-VA hospitals experience on average at least one drug error each day they are hospitalized, according to a study by the Institute of Medicine.

As it happens, the idea for the VA's pioneering, automated dispensing system, and much of the software that drives it, came from a VA nurse. While returning a rental car in 1992, the late Sue Kinnick noticed an employee using a handheld device to scan a barcode in the trunk of the car. A light went on. "If they can do this with cars, we can do this with medicine."

As I relate in my book, Best Care Anywhere: Why VA Health Care Is Better Than Yours, there's a similar story behind nearly all the health IT pioneered by the VA. Its programs were originally conceived of and written by VA employees for VA employees, in a non-proprietary code, through a highly collaborative process we would today recognized as "open source" software development. It was a revolution from below, brought off by frontline employees who, beginning in the 1970s, were trying to work around the general dysfunction of the VA's central office.

To those familiar with the increasing commercial dominance of open source software in other realms, it should come as no surprise that the VA's open source code, now fully integrated and known as VistA, is the only health IT system to succeed in gaining widespread doctor buy-in and implementation. Signaling the wider importance of the VA's bottoms up revolution in health IT, VistA is already up and running successfully in many foreign countries, including Norway, Mexico, Egypt, and (soon) Jordan. Both West Virginia and Hawaii are also moving rapidly to install it in their public hospitals and clinics.

Yet here is the danger. Under pressure from the Bush administration and some members of Congress, the VA has been forced in recent years to recentralize and outsource much of it's health IT. The early results are ominous. For example, last August 31, VA hospitals throughout the West, and including Hawaii, Alaska and even the Philippines, lost access to their digitally-driven records and devices for a full day. This occurred when a single server in Sacramento, now hosting all VA computer operations in a region spanning one-third of the globe, went down. In an article entitled "Crisis at the VA," former VA contract employee Roger Maduro gives a devastating account of the potentially life-threatening failure. He also shows how it relates to alarming decision taken by the VA's political appointees both to recentralize management of VA health IT and to begin replacing VistA with commercial software. For further information see also articles written last week by Dana Blankenhorn here and here.

As our country considers how to reform the health care system, we would be wise to learn from the VA experience. Everyone agrees that health IT must be part of the solution, and we must find a way to replicate the levels, integration and innovation achieved at the VA across our whole system.

QUALITY: Physicians Healing Thyselves (or at Least Their Offices)

Joanne Kenen — Thu, 03 Apr 2008 20:45:00 -0400

Tired of waiting for Washington to fix health care, doctors across America are doing it themselves. I just attended a conference in Dallas where hundreds of physicians exchanged ideas on how to improve the quality of care they deliver, make their clinics more efficient—and rediscover the joy of practicing medicine. In future posts, we'll touch base with some really smart and dedicated people we met there and highlight specific innovations that got our attention—new ways of reaching hard-to-serve populations, managing chronic diseases like diabetes, involving patients in their own care, new twists on "shared visits."

But here's our basic takeaway on how the 9^th annual summit on Redesigning the Clinical Office Practice, run by the Institute of Healthcare Improvement, could contribute to the high quality, cost-efficient and caring health system we envision for the future: as we noted when we posted on former Gov. John Kitzhaber's keynote on Monday, IHI and its CEO Dr. Donald Berwick (pictured) get a ton of (well-deserved) attention but mostly for what they are doing in the inpatient world, fighting hospital-acquired infection, developing rapid response teams and the like. (Yes, for any health policy newbies among our readers, IHI is the make-doctors-wash-their-hands-and-send- their-ties-to- the-cleaners-now-and-then" group.) Maybe figuring out how to apply "queuing" theories that work in supermarket checkouts and LEAN business practices to outpatient primary care isn't as sexy to the headline writers but it's just as important. Reducing wait times— waiting time to get the appointment and then all the time we sit around in waiting and exam rooms—isn't just a matter of convenience. It's about reducing waste, freeing up time and resources so people get the care they need, when they need it.

There was lots of talk about electronic medical records (one session was called "Going Digital Without Going Bankrupt") but a lot more talk about patients. How to streamline office practices so instead of having three nurses answering the phones you can have two on the phones and the third working one-on-one with a chronically ill patient, keeping them out of the hospital. How to create a "medical home," where a patient's care is truly coordinated by a primary care team that knows the patient instead of fragmented care by a half- dozen specialists flung across various clinics and hospitals, none of whom knows what the other is doing. Dr. Carole Redding-Flamm, executive medical director of Blue Cross Blue Shield Association, described Patient-Centered Medical Homes that are up and running in several states, rural and urban. The insurers, in some cases, are paying the doctors extra for successfully managing the care. An extra benefit, doctors report, is higher rates of patient satisfaction.

One high risk time for patients is transitions, for instance from the hospital to home health care. It sounds like a no-brainer to say that sick, frail people at high risk of finding themselves back in the hospital within a month need more than an occasional visit from a home health aide. But in reality, that's sometimes all they get. Consultant Ann Hess described a pilot program between Mt. Sinai Hospital in New York and the Visiting Nurse Service of New York. She showed how getting a nurse practitioner to a home-care patient soon after leaving a hospital reduced the rehospitalization risk. But that required tools for assessing the risk so that the nurse practitioner (who costs more than a less skilled home health aide) goes where she is really needed. It also requires getting the patient to see a doctor after a high-risk hospitalization within seven to 14 days (which often does not happen - that's where the smart business practices and reduced waiting time makes a big difference to the quality of care).

The "reinventing clinical practice" concept is an exciting one to anyone who has spent years in Washington (where all too often policymakers reinvent stalemate). One thing we'd like to see happen in this blog is for policymakers to hear about clinicians who are creating change, and for clinicians to understand how policymakers are beginning to understand some of the linkages between cost, quality and coverage. If you know any "clinician innovators" with good stories to tell, please post a comment and let us know.

IN THE STATES: Pennsylvania Governor Backs Coverage Plan

Joanne Kenen — Wed, 19 Mar 2008 22:04:00 -0400

Brief update - As expected, the Pennsylvania House did approve a scaled-back version of Gov. Ed Rendell's health coverage plan this week. Rendell has now embraced the compromise and strongly urged the state Senate—which has been more skeptical about the finances—to pass it. As coverage expansion needs to go hand in hand with insurance market reform, particularly to help small businesses and individuals purchase policies, Rendell is also pushing for an insurance package in the House. AP has the details.

Also in Pennsylvania - Patients can now go to a single user-friendly web site- instead of a confusing array of them - to learn about local hospital quality in four key areas: heart attacks, heart failure, pneumonia, hospital-associated infections. The site was developed by the Pennsylvania Health Care Quality Alliance - a coalition insurers, hospitals, doctors and government agencies, the Philadelphia Inquirer reported.

"Our goal has been to work together on a common way of understanding and sharing the quality measures data that providers are already required to report," Carolyn F. Scanlan, president of the Hospital and Healthsystem Association of Pennsylvania, said in a statement.

INNOVATORS: Brooklyn 'Cyberdoctor' Harnesses Health Tech for the Hip

Joanne Kenen — Wed, 19 Mar 2008 15:51:00 -0400

You know the clichés about bloggers in their pajamas? Well, we think the Health Care Blog has found the medical world's equivalent - a young doctor in Brooklyn who runs a "virtual office" from a laptop in his bedroom. (On the youtube video, however, he was not in pajamas). We don't agree with Parkinson about everything - his cyber-savvy practice catering to young, uninsured but artsy New Yorkers who can't afford insurance but can pay $175 for an occasional visit from a young artsy New York doctor (Parkinson is also a photographer) isn't a model for fixing U.S. healthcare today and it's easy to be cavalier about being uninsured until you get a high-cost illness or are struck by that proverbial bus. But we like seeing creative ways of harnessing efficient and patient-friendly high tech into doctor's practices. Parkinson's patients, for instance, can book their own appointments at their convenience in his online calender without anyone putting them on "hold." And we were fascinated not just by the post on him but also the comments it has provoked from readers.

Parkinson operates out of the Williamsburg section of Brooklyn, making house calls to his patients. He keeps their medical records, test results and x-rays on his laptop, and uses the Internet for many routine purposes, cutting out administrative staff and costs. Patients don't have to spend an hour in a waiting room or play telephone tag to get referrals, prescription renewals and the like. Parkinson also answers patients' questions via computer and checks labs and tests that he can access online. Lots of it makes sense for patients that are reasonably young with health issues that are reasonably easy to manage. (Although until someone figures out how to resolve the myriad challenges of online privcy and how to make various electronic records systems compatible, a cyberpractice can only reach so far.) We don't think his approach would work as well for other populations - people who are older, sicker, poorer or just not as Internet-savvy. And we would rather fix the health insurance system than just say how terrible insurers are. But we liked his enthusiasm, dedication and eagerness to bring doctors' practices -- not just high tech tests and devices -- into the 21st century.