Gingrich's grand vision: A medical world without paper

Newt Gingrich is a man who always had big plans. When few thought the Republican party could wrest control of the House of Representatives in 1994, he sold the electorate on his "Contract with America," leading his party to a majority victory and getting nine out of the 10 items in the contract enacted into law.

Unfortunately for Gingrich, the bottom fell out when he had to pay a $300,000 fine imposed by the House for ethics violations stemming from a book deal, and when the electorate, in a possible backlash over Republicans' role in the impeachment of then-President Clinton over the Monica Lewinsky scandal, elected more Democrats to the House. Although the GOP retained control, Gingrich resigned as speaker in January 1999 and left the House.

The setbacks haven't stopped Gingrich from making more grand plans. Now he's trying to sell the country on a Web-based national health information infrastructure.

"The more I looked at health in 1999, the clearer it was that it was an area that badly needed a transformational approach that would bring it into the 21st century in terms of information technology and quality systems and best practices," Gingrich said. "No serious person can debate that having disaggregated paper records isn't an invitation to killing people."

To promote information technology in health care, Gingrich has written a book, Saving Lives and Saving Money, and founded the for-profit Center for Health Transformation, an organization whose members, which include health technology companies, pay $1,000 to $200,000 to join. Rep. Patrick Kennedy (D, R.I.) has said he plans to introduce Gingrich-backed legislation to implement a paperless health care system by 2015.

American Medical News spoke with Gingrich.

Question: Can technology cure what your book describes as a broken health care system?

Answer: It's not the total cure ... but it's less expensive to be paperless, it's more accurate, you avoid medication errors, you're able to identify problems [more easily and quickly].

There are three layers of change coming in health. The underlying basic level is a scientific and technological revolution, which will drive change so that in the next 25 years we will see as much change as we've had in the last 100 years.

The midlevel is getting doctors and institutions to ... routinely use electronic information. The top level is getting the individual back in the health system with individual incentives, individual information, individual choice and individual responsibility. If all three of those happen, you will have created what I call a 21st century intelligent health system.

And you will have begun to really dramatically lower the number of people dying unnecessarily and [begun] saving an amazing amount of money.

Q: What do you think about the findings that information systems can have unintended consequences? At Cedars Sinai in Los Angeles, for example, doctors revolted against the computerized physician order entry system.

A: I'd say that's part of the problem. You have this cottage-industry model where people refuse to adopt already successful systems. It's amazing to me how many hospitals go out and spend millions of dollars and several years utterly unnecessarily trying to build a unique, handcrafted system for themselves instead of looking around at the 10 or 15 major vendors who do this every day for a living, know what they are doing, have a proven track record -- and I'm not arguing [for] any one vendor. I'm just saying there's a whole bunch of them out there that are really good, that are worth looking at.

So you need to improve the systems. This is [like] saying in 1906 that the automobile still has problems. That's true. But the future is going to belong to the automobile. It's going to get bigger, better every year. There is -- and I'd be glad to debate anybody on this -- no justification for a paper-based system in the 21st century. Paper kills.

Q: What should the national health care information technology infrastructure look like?

A: Let's start with [patients] having an individual health record that [they] own and follows [them] wherever [they] go. The doctor can co-own it, the hospital can co-own it. It allows your specialist to look at it at night when they are at home or on the weekend if they are on vacation.

Second, we'll have very large depersonalized databases. If we turned over the Veterans Administration, TRICARE, Federal Employee Health Benefits and Medicare's databases today, the federal government may have 500 million life years of data it could access -- that is lives times years of record. That would be the richest database for outcomes research in history. You can then begin to accelerate dramatically the [introduction] of new drugs because you can find from individual health records people who are eligible for that particular trial and give them the opportunity [to be in it]. People could say, 'Yes, I'd like to know if there's a new, better medicine for my condition.' So it's not a question of privacy violation.

Q: Any other elements?

A: The greatest threat in national security that we face is an engineered biological [agent], which will be much, much worse than [people think]. We could conceivably lose 30 million to 50 million people to the right kind of engineered biological [agent]. That means we need to build a virtual public health system.

Q: How should this national IT infrastructure be implemented?

A: One of the steps we proposed is that the federal government in January pay for an [electronic] individual health record for citizens who are 65 years old next year [and] who get the welcome-to-Medicare physical. This just starts in January. ... We believe you can do that for $10 a person to launch it and $3 a year to sustain it, and probably another $10 for the doctor to input it.

Q: How did you come up with these figures?

A: I have four major companies that have come in and said they will bid that price. ... See, [the cost] is dramatically lower than people thought. But that's because it's a Web-based encrypted system with a central server. We're not going to try to go out and create 6,000 silos, but it's exactly a Microsoft, AOL, Google or Yahoo model.

Q: Can you identify the companies?

A: No, I wouldn't feel comfortable doing that. They are all big; they all have track records.

Q: Are you proposing the mandatory use of electronic medical records by physicians?

A: Probably by the end of the decade; not right now. But yeah, ultimately. In the long run, it will be malpractice to have paper records because you kill people [with them].

Q: What role will office-based physicians play in the development and implementation of this IT infrastructure in health care?

A: Obviously, it has to fit their workflow patterns. I think it ought to be done in ways that make it easier to be a medical doctor, not harder. But my hunch is that when we get to an all-electronic system, the places where it's actually set up, doctors will end up liking it a lot. It's better than being kept on hold. Forty percent of all prescriptions lead to a call back by the pharmacists. Think of the lost time and energy that implies.

Q: President Bush is proposing $100 million to get the initiative off the ground. You have cited England as an example of the health care industry's state of computerization. England has a single-payer system and plans to spend about $11 billion to create a national health IT infrastructure for its 49 million residents. How feasible or realistic is it to expect that the U.S. can implement a similar system?

A: My hunch is that the U.S. government spends more on health IT than Britain does. If you take TRICARE, Federal Employee Health Benefits, Veterans Administration, Medicare, Medicaid, Indian Health Service, my guess is we actually buy more computer power. But we do it in a disaggregated silo manner. ... We have 44 million people in Medicare alone. So if the federal government were a smart purchaser, it could migrate the system to IT very fast.

Q: Can a national IT infrastructure happen without government involvement?

A: No.

Q: As you go around the country talking about your ideas and vision, what do physicians say?

A: The younger ones all think it's clearly doable, and the older ones are all skeptical. That's not totally true. I know some older doctors who are very pro-technology. But I'd say, as a general rule, almost no younger doctors think that they will spend their career with paper. They don't know how it will quite evolve but they stipulate that it's going to happen.

Q: Do they complain about the cost of technology?

A: Sure. All small businesses complain about all costs because it's personal. It's their income and because they see somebody else dumping on them without a profit. But if you work out a way to mutually incentivize -- that's why I think we ought to pay the doctor $10 for a physical to get it into an electronic system -- it's worth it to the larger system in the long run to do that.

Q: Would you suggest that the government subsidize the cost of technology and EMR systems for physicians?

A: I'd pay for the outcome rather than the technology. I'm willing to pay a little extra for electronic prescribing, I'm willing to pay a little extra for electronic medical records, but what I want [to pay for] is the product, not the investment.

Q: Who should pay for the investment then? The doctors?

A: Sure. But if they are going to pay for it upfront, they can borrow against the float. Again, it's something every business in America is doing.

Q: Surveys have found that initial start-up costs for EMRs range from $20,000 to $50,000 annually per physician. Should doctors be expected to pay for the technology themselves?

A: I'd ask them why they think it costs that [much]. I mean go to Microsoft and ask them what it would cost to create the software. Microsoft would sell that software for $105.

Just go look in every other field [like aerospace where the first airplane is expensive to build but the 300th is a lot less]. Only in a field that has maintained the gild-like fascination with small unit production. In the 1890s, there were 400 companies building cars in Michigan, and all of them built three or four cars a year. And they were all expensive, and they were all unreliable. In 1905 Henry Ford built a mass-produced car. Prices crashed overnight. The car was much more reliable, and people began leaving the horse and buggy.

Q: So you don't believe this figure of $20,000 to $50,000 per doctor per year?

A: No. I can't tell how they get to it.

Q: Do you see a role for technology in addressing the uninsured, underinsured and the working poor?

A: I think we will save so much money in the next decade by having an intelligent health system that we will be able to have a tax credit and a voucher system to enable virtually everybody to be insured.