[Second Annual James Cassedy Memorial Lecture; “The Information RX"]

[Nancy Tomes, Professor, Stony Brook University; Tuesday, July 7, 2009]

[Elizabeth Fee:] The memorial lecturer.

Jim Cassidy was for many years, I would say, the backbone of the

History of Medicine Division. He was responsible for producing the

bibliography of the history of medicine, the printed version and later HISTLINE,

which many of us grew up professionally on.

And he was also the author of many very

fine books and articles dealing with the history of medicine and public health.

So, I remember when I first

came here and met Jim,

he was already of an age when many

men are thinking of going fishing.

And he said to me in so many words,

"I don't want to retire, don't make me retire."

And I said, Jim, are you crazy?

I want you to stay for as long as you

possibly can, working as hard as you can. And that's exactly what he did.

And I remember some of you here may remember when he received the 50

year pin-- for 50 years of government service and I was very touched by

how pleased and proud he was to have been able to serve so many years.

He did also around that time when the Lifetime Achievement Award of the

American Society for the History of Medicine.

And so to remember, Jim, we have instituted this lecture series

where we will invite distinguished historians of medicine to come

and present to us. And before I introduce our speaker for today,

I would like to ask Jim's widow, Carol Clausen, who also has a long and distinguished

career in the History of Medicine Division, has she's asked, she would like to say a few words.

Carol,

[Carol Clausen:] First of all, I want to thank Liz Fee and Steve Greenberg for setting up this lectureship.

I'm sure Jim, in his very modest way, would have been very pleased and honored.

When Jim died, several people asked me what had become of the work on

John Shaw Billings that he'd been working on so long and so lovingly.

And at that point I really didn't know, it didn't have a publisher. He'd completed it.

Recently, with the help of Doctor [Donald] Lindberg

I have started looking into "on demand

publishing" and it seems very feasible. Produces a very handsome product

and I really, I expect that before the next lecture, in fact, maybe before the end of the year his

book will be out and it will be available. Little little plug for it.

[Laughter]

[Applause]

[Elizabeth Fee:] I should perhaps have said

my name is Elizabeth Fee. I'm head of the History of Medicine Division here at the library.

Some of you might be wondering why the hat. I just recovered from brain surgery.

So to cover up my scars, I'm enjoying hats for a while.

And now I'd now like to particularly welcome our speaker for the afternoon.

Nancy Tomes received her PhD from the University of Pennsylvania.

She is currently Professor and chair of the History Department at Stony Brook,

the State University of New York. Her major publications include

a most delightful book. If you haven't read it,

you should.

"The Gospel of Germs. Men, Women, and the Microbe in American Life."

It is published by Harvard University Press in 1998,

which won the 2002 Welsh Medical Medal. [Welch Medal]

Excuse me, from the American Association for the History of Medicine.

And she's also created the Medicine and Madison Ave.

website at Duke University.

Nancy is a master at picking topics for research and her-- choice of the

topic today is aimed directly at the heart of what we all do here at

the National Library of Medicine. Her title is "The Information Prescription." [Rx]

Please join me in welcoming Nancy Tomes.

[Applause]

[Paper shuffling]

[Nancy Tomes:] Indeed, I'm very aware of the

bringing coal(s) to Newcastle phenomena in presenting this talk. It's a pleasure to be here.

It's a pleasure to be here delivering a

lecture named in honor of James Cassedy, who was very kind to me

when I was a young sprout, starting out and learning my way around the history of medicine field.

Which is very welcoming to young scholars. So it's it's a pleasure to be here,

particular pleasure. The talk I'm going to be giving today is drawn from a chapter that's

going to appear in a book about medical professionalism and information technology, edited

by David Blumenthal and David Rockman. And it's funded by the Robert Wood Johnson Foundation,

which we are have been researchers. As you're probably aware,

there's enormous enthusiasm today for all forms of information technology,

which are being promoted as a sure cure for every problem in the American healthcare system.

Who needs National Health insurance? All we need to do is to give doctors,

Palm Pilots and BlackBerry or so that the enthusiasm can run.

Well this volume is trying to prompt a more realistic assessment of what

changes information technology might

bring to the delivery of healthcare. And it's-- it's publication has been

slowed down by the amazing fact that David Blumenthal was selected by

President Obama to be his information technology advisor. About which all

of us who have been kind of feeling like in a backwater suddenly they're

the interest in the topic was we-- we might actually have some some impact.

My contribution to this volume was to look at the issue of consumers

and consumer health information. Obviously a huge topic. And as you'll see,

I'm not focusing on all forms of of the information prescription

and in fact not going to be talking about the kind of very important

work that the National Library of Medicine has been doing in terms of

of the development of MedlinePlus. I'm really interested after the talk

if any of you can come share to me, share with me your your experiences

in the end of the Information RX that that you work with, I'll be delighted to hear it.

But my focus today is going to be on a particular subsection of ratings

and rankings and the way they've evolved. Again, I'm a historian,

so I'm going to be giving you a long range historical perspective,

but I hope you'll find it interesting. In October 2007, the Zagat Survey,

the company best known for its popular restaurant and hotel guides, announced a new venture.

A Zagat's Guide to Doctors, in collaboration with Wellpoint Inc,

the nation's largest health benefits company. Zagat began in January 2008 to collect

information about patient satisfactions with their physicians on 4 criteria. Trust, communication,

availability and office environment. And to use that data to rank doctors

on a 30-point scale similar to the one the company had developed for hotels and restaurants.

As Nina Zagat, the company's co-founder, enthused "with this tool, Wellpoint is helping to give

consumers the power to make smart decisions about selecting doctors

based on other people's experiences." Zagat's entry into the doctor rating

field prompted a range of responses, from the amused to the skeptical. Quote, "Would you like dessert

with your diagnosis?" end quote, one headline read. While another observed that "soon

we could use," the 'burgundy bible,' "both to discover the best restaurant in

town and then to find a doctor to treat the stomach ache that followed the meal."

The president, as you might expect, physician reaction to the Zagat's

guide was particularly chilly. The president of the American Academy

of Family Physicians warned, quote, "Choosing a physician only according

to consumer ratings can deprive patients of high quality medical care,

particularly if those ratings are based on unrecognized and unvoiced anger

or unjustified allegiance." But in spite of such warnings, the enthusiasm for consumer rankings,

report cards, and other such information tools seems here to stay in the United States.

Besides the Zagat Wellpoint survey, patients can now go online to sites such as Rate,

MD Com, Vitals Com and Doctor Score Com to share

their opinions about specific doctors. The so-called peer-to-peer evaluations

join a field already crowded by other types of information sources intended

to help patients make better choices. Some focus on therapeutic issues, for example is this the best

treatment or the best hospital for me? Others concentrate on cost effectiveness.

Is this the most economical use of my healthcare dollar. In tandem with

similar efforts aimed at better assessing physician performance,

the trio of acts of

assessment information. I'm sorry, quality assessment and information technology

is frequently held-- hailed as a promising new direction in healthcare reform.

this Information RX that is providing more and better information to

individual consumers as a way to reform the American healthcare system

reflects an underlying assumption that the healthcare market needs to

be become needs to become more like other aspects of the American economy.

If only consumers had access to the same quantity and quality of information available for goods

such as appliances or automobiles, so this argument goes, they could be a powerful force

for improvement. With better information about physicians, hospitals, and insurance plans,

consumers will reward the good and avoid the bad,

thereby turning the power of individual

choice into a powerful tool of change. The proliferation of decision making

tools offered the American patient consumer today illustrates the great faith in what art historian

Theodore Roszak once referred to as the "God Word of information," a word that he wrote,

enjoys "the mystique once reserved for reason, faith, and grace." The Information RX,

as well as the larger field of quality assessment upon which it rests, has gained this exalted status

for many reasons. Chief among them the good fit between this emphasis on individual

preference, information and a decentralized, marketized healthcare system.

That has evolved in the United States since the 1970s. More and better consumer

information is one of the few policy goals on which liberals and

conservatives alike have consistently been able to agree since the 1970s.

The political appeal and ideological

expediency of the Information RX makes it

all the more difficult to question its value. In writing about this topic,

I'm often reminded of a book by [?] that I had to read as a graduate student.

I was basically about how you couldn't be an atheist in the 16th century. It was just impossible to

imagine a world without God. Well, I often think about that,

that it's impossible to be an atheist on the subject of information in the 21st century,

and I want to hasten to say that I am not against information in the least.

I think it's a good thing. However, what does it mean?

And we need to think a little more reflectively about what

information means, how it's used, what its purposes are? So my intention here is not to

discredit the idea that consumers deserve good information, a principle that is hard to dispute,

but rather to raise some more basic questions about what constitutes good information.

In the hope of encouraging a more realistic appreciation of what the consumer information

RX can and cannot accomplish. Now my argument here employs what

at first glance may seem like an irrelevant methodology, and that is history.

One of the most common assumptions about the modern information revolution is

that it is without historical precedent. The Zagat's guide and all it represents

that is patients using the Internet. Consumers driving the healthcare market,

are invariably presented as an innovation without precedent. There's something new under the

sun that has no history. To the historian, at least to this historian,

that kind of claim is like catnip to a cat or red meat to a dog.

It is an assertion that begs for contradiction. Hence the purpose of this paper today,

or this talk, is to sketch the history of buying guides, report cards,

and other rating devices aimed at patient consumers. And again,

I'm not going to be looking at the many other kinds of information that are

part of the consumer health revolution, but just at the concept of a buying guide,

a report card or rating devices. And in so doing, I have three goals. First,

I want to counter simplistic historical narratives that overemphasize the role of the Internet as the

starting point of such developments. Again, this is not to say the Internet isn't important,

it's enormously important, but to say that it's continuing trends

that were in full flurry as of 1997. So that's number one,

#2 I want to complicate the meaning of 'consumer information' is a policy keyword.

And 3rd I want to highlight the changing definitions of information expertise and who can own it

and use it that have occurred over the last half century. As we shall see,

the Information RX has been, not unlike the modern prescription drug.

Highly effective in correcting an underlying pathology but accompanied

by some unexpected side effects. A better understanding of its

benefits and risks may help to improve the next generation of remedies.

So let me start here with a general discussion about information

technology and report cards. My argument here is building on a

broader scholarly effort to put the late 20th century information age into historical perspective.

Inspired by the work of Daniel Hedrick, Theodore Porter, and Sarah E. Igo, to name just a few,

I seek to look at how new forms of consumer health information have

themselves helped to create and define the very concept of a modern health consumer. As such,

consumer guides to healthcare constitute a very revealing technology of knowledge,

as science studies people call it. That is a means of collecting and organizing

information toward a specific end, in this case improvement of a healthcare service or institution.

Consumer ratings and rankings depend for their utility on an easily

quantifiable and understandable metric. The numbers conveyed are usually simple

descriptive statistics such as percentages, which are harnessed to a system of grading.

Usually or very simple, ranging from excellent to unacceptable. Their construction requires the

identification of a limited set of qualities or conditions to be measured, such as mortality rates or

post operative infections, and these benchmarks stand in for a more global assessment of

performance or value that would be too time consuming to to construct.

While producing a rating may require many hours of complex data analysis,

the final form is usually pretty minimalist in its presentation. Since the 1970s,

computer assisted technologies have made it far easier to compile such rankings and ratings,

and thus their appearance is often assumed to be a direct effect of the computer revolution.

But again, as historians have noted, modern information systems

originated long before the computer. The predecessors of the modern consumer guide were in fact

produced by simple hand tabulations and statistical expressions.

That connection is evident if you think for a minute in the word 'report card,' itself.

Which we now use to talk about this new consumer to refer to this

new consumer oriented information. The report card was a historical

product of the American public school system. Introduced in the late 19th

century to standardize and improve the quality of the public school system.

Although so again those of you who are Americans have gone through the public

school system have all gotten report cards, so you know what I'm talking about.

Interestingly, although they did not refer to them as report cards, 19th century healthcare reformers

use utilize very similar methods. The contemporary quality assessment movement, for example,

traces its origins directly to the work of Florence Nightingale and her her work on hospitals.

Certainly if they're historians in the audience, one of the most famous grading exercises

that we would all immediately come to mind was in the early 20th century, and that was the landmark

1910 Flexner Report. Abraham Flexner and his associates created

a Medical School Report card based on benchmarks that they felt captured

the quality of a medical education. For example, what percentage of medical students had a

college degree before entering, and how much time students spent in

bedside instruction and so forth. During the same time period,

the Boston surgeon, Ernest Amory Codman developed an equally ambitious

plan to access the quality of hospitals and physicians services.

Codman's called this his 'End Result System'  [Idea] did not have nearly the immediate

impact that Flexner's report in terms of becoming a tool for assessment.

But it did end up having an important long term influence in that it shaped the American

College of Surgeons. Voluntary Hospital Accreditation program,

which in turn was later picked up and

expanded upon by the Joint Commission on Accreditation of Hospitals.

But prior to the 1960s, these kinds of grading exercises

figured only as tools of expert assessment and policy formation.

They were meant to be compiled by experts and to be used by experts. In other words,

Abraham Flexner did not intend the Flexner report to be used by medical students

looking for a good medical school. Nor did the the American College of

Surgeons think of its accreditation program as being useful to patients looking for a good surgeon or

a good hospital. The limited accessibility of information about healthcare reflected the

prevailing conviction that patients laypeople could never evaluate the true

value of the medical care they received, but rather needed to rely on

their doctor's guidance in making choices about treatment. In this respect,

accreditation reviews and rankings differed greatly from the

student report card. That was always a technology of knowledge explicitly

designed to be shared with the pupil and her parents as a way to improve. The hospital rankings

and the the accreditation rankings were not meant to be shared with the user,

but rather with the hospital that the physicians and

hospital leaders delivering that service. This patients should be seen but not heard

attitude stood in marked contrast to a new concept of rational choice in

the marketplace that developed outside medicine during these same decades.

Again starting at the turn of the last century during The Progressive Era.

The idea that educated consumers,

who began to catch on in many other

areas of American life. Think of the safety of food and medicines

as reflected in the 1906 Pure Food and Drug Act that created

the Food and Drug Administration. During the same time period,

the home economics movement taught generations of American women to

regard careful shopping habits as a badge of domestic virtue. As a mass consumer economy expanded

in the 19 teens and 1920s, this ideal of careful consumption spread along with.

It was an idea born and prosperity that became even more popular during the Great Depression.

When economic distress only intensified the importance of making wise

shopping choices. In this climate, a new kind of consumers buyer buying

guide became popular in the 1930s. Based on a very different conception of

expertise than that embodied in the medical school and hospital accreditation processes.

The Depression Era Buyers Guide offered what today is referred to as peer-to-peer evaluations.

The end users of the product, in other words, the consumers, sought to share their knowledge

with their fellow consumers. And this approach was exemplified in Consumers Research,

founded in 1929 and later by its rival Consumers Union,

founded in 1935. And Consumers Union went on to found

what in the 1970s became a highly

successful empire of consumer guides that

you probably know is Consumer Reports. These early consumer buying guides

focused on mass produced products, not professional services. The the because the former were

were much easier to test and to categorize. In light of the patients should be seen and not heard

philosophy dominant in the the 1930s, therefore raised in the healthcare

concentrated chiefly on denouncing the proprietary medicine companies

and also alternative medicine. Positions that on the surface made their work compatible with that

of the powerful American Medical Association in this time period. Despite their cautious tone,

however, these early consumer organizations were persistently portrayed

as anti-American and

fronts for the Communist Party. Subject to a great deal of the red baiting from

the 1930s through the 1950s. Even though today it's hard to imagine

they they faced a great deal of resistance well into the the 1950s.

Still, the concept of the consumer buyers guide found a receptive

audience among middle class Americans, particularly the college educated and

a professional groups who had growing confidence in their own powers of judgement.

The political and cultural upheavals of the 1960s created a far more

hospitable climate for the concept of this educated consumer.

In the wake of the civil rights anti-war students and consumer movements, activists

singled out the medical profession, and the hospital industry as particularly complicit in the

maintenance of a repressive social order. A common characteristic of the many

patient advocacy groups that sprang up in the 1960s and 1970s was a shared

faith in more democratic decision making. And that democratic decision making

required that consumers have better information about healthcare providers,

treatments, and institutions. That tight link between empowerment

and information was well illustrated in the founding of Public Citizen. The Consumers Organization,

founded by Ralph Nader in 1971, was one of a new breed of citizens

advocacy groups that Michael Pertschuk christened the "Giant Killers." Because they were small,

but they could bring down the establishment. Or that was what they hoped to do.

Public citizens sought to combine critical information gathering with effective political action.

Healthcare was among its earliest objects of critical scrutiny,

evident in the creation of the Health Research Group headed by physician

Sidney [Manuel] Wolfe. It was one of the it was the first a Public Citizen specialized

subunits. Arguing that American healthcare had been dominated by special interests for particularly

the AMA as well as the hospital, pharmaceutical and insurance industries.

Public Citizen called for research based advocacy to protect patient consumer interests.

This research based advocacy took many forms. Initially, Public Citizen Publications simply

compiled and analyzed evidence from government reports. The information to critique policy

was right there, already in print. All you had to do was rearrange it a little bit.

But as consumer advocates quickly realized, the kind of information that newly

empowered patient consumers might want to make informed personal choices was still very inaccessible.

So they had the idea of creating new bodies of data that might be more useful.

One such effort consisted of publishing a consumers guide to local physicians.

Although medical societies had long made available lists of their member doctors,

they resisted the sharing of more specific facts about fees and treatment philosophies.

The consumer advocates regarded this refusal to share such information

as symptomatic of the medical professions undemocratic tendencies.

If patients were ever to get better treatment, this medical monopoly,

as they called it on information, had to be challenged. One of the most publicized of such

efforts took place in the early 1970s, right here in Washington Regional Area.

When a group affiliated with Public Citizen compiled a directory of physicians in Prince George's County--

suburb of Washington, DC. The directory did not try to rate physicians.

We weren't there yet. But it's simply aimed at giving patients basic information

about the physicians practice such as his or her office hours, fee scales.

And in addition, the directory makers sought to find out if doctors were willing to prescribed

contraception for unmarried women, which was very big issue in the early 1970s.

When the local medical society learned of the directory project,

it told its members not to cooperate, arguing that it constituted a form

of physician advertising which was forbidden by the AMA code of ethics.

What ensued was styled by the media as a kind of David and Goliath battle between the medical

society and the consumer activists.

And perhaps the most important outcome of this was that it attracted the attention

of the staff at the Federal Trade Commission, which had become interested in professional

groups and how they used advertising bans. The Prince George's County Directory

incident in fact helped inspire the FTC

in 1975 to file a lawsuit against the

American Medical Association. Against the

AMA as historic ban on physician advertising. And after fighting this for

a good number of years, the AMA lost and was forced to lift its

ban on physician advertising in 1982. Ironically, and this is something I come across

over and over again in my research, consumers request for more

information led to more advertising. Similar controversy surrounded the

creation of the first self styled Buyer's Guide to Hospital Care, which appeared around the same time

as the Prince George's Directory. Again, the idea for such a guide came from a Nader protege,

in this case, Herb Denenberg. A Penn law professor appointed Commissioner of Public Insurance

for the State of Pennsylvania in 1971 by the newly elected Democratic Governor Milton Schapp.

Schapp wanted to make the state's Department of Insurance more protective of policy holders.

Like the Maryland activist, Denenberg adopted the concept of a 'Shopper's Guide' as a way to promote

more informed consumer choice. During his term as commissioner his office put out a series of such

guides on automobile and life insurance. But the 1st and most controversial

of Denenberg's New Style Buyers Guide was his 1971 Shopper's Guide to

Hospitals in the Philadelphia area. It was even more modest in appearance

than the Prince George's Directory, and believe me, I've seen the originals of these

and it's hard to believe these skimpy little things could have led

to such a firestorm. Denenberg's Shoppers Guide consisted of a

one page fold down, listing daily rates, bed capacities and average length of stay,

and included information on deficiencies, in particular the number of unsafe beds.

Which he was able to get from a report made by the Pennsylvania Department of Health Education.

Denenberg wrote, quote, "The public may not be in a position to shop for a hospital,

especially in view of a doctor's requirements in his hospital connections, but it is entitled

to information that will permit comparisons." As of the early 1970s

the pressure that consumer advocates such as Denenberg could bring it to bear

in prying open existing data sources, however, was still very limited.

Denenberg, for example, was very quickly caricatured as anti-business.

He met with extraordinary resistance from the insurance industry in Pennsylvania.

He finally left the commissioner's position in 1974 to make an unsuccessful run for the US Senate.

But significantly, he found a second rewarding career as a journalist and television

personality in Philadelphia, where he pioneered an early style

of muckraking 'shame on you reportage' that has since become a staple

of the American news industry. So what he couldn't do as a public official,

he was able to do as a journalist. In the early 1970s

healthcare critics demanded more neutral information and greater institutional transparency.

Requests they presented as rational and scientific, but that their critics still tended

to dismiss as the imaginings of wild eyed radicals. However, over the next decade,

from the early 70s to the early 1980s, profound changes took place in the

political terrain that domesticated this concept of an educated health consumer.

And I'll just mention some of these. I don't have time to go into all of them,

but certainly the growing influence of economics and health policy discourse.

The post Watergate pressure for greater transparency in government. The renewed emphasis on personal

responsibility and accountability after the counterculture, and the rapid development of computer

assisted technologies all converge to create a new era of accountability, as it was called.

In which information sources designed for the use of patient consumers would flourish.

This era of accountability reflected first and foremost the vast increase

in Federal investment in healthcare following the creation of Medicare and Medicaid in the mid 1960s.

These new government programs generated massive databases concerning

physician and hospital practice, as well as created intense pressures for cost containment.

The same time federal agencies and accrediting bodies were compiling more such information,

new computer assisted technologies emerged that were far more effective in processing it.

Now the pathway from computers to report

cards was both by no means a a direct one. The first effect of the computer revolution

was not to democratize information, but rather to create a new group

of experts that was skilled at assembling and analyzing it.

And just a brief this audience. You're more probably sophisticated about

these topics than my fellow historians, but let me just fill you in a little bit of this.

Starting in the 1970s, integrated circuits and miniaturization

made possible a new generation of computers, including supercomputers capable

of processing huge amounts of data and many computers able to process smaller amounts of data for

individual researchers and businesses. The great leap forward and electronic

processing made it possible to do far more sophisticated forms of evaluation. In particular,

computer assisted technology facilitated the spread of a new kind of systems oriented thinking,

that originated in business and government during the late 1950s and

here the work of Avedis Donabedian, a physician and public health professor

at the University of Michigan, was was a critical turning point.

In the 1970s and the early 1980s, researchers began to apply computer assisted technologies

to the study of medical outcomes. Tabulate-- tabulating everything

from the number of particular procedures performed to the rate of hospital based infections.

As might be expected, these analysis uncovered many areas in which providers and hospitals were not

performing either consistently or well. A case in point was the work of

Jack Wennberg and his colleagues at the Dartmouth Medical School, who documented local variations

in medical practice that could not be explained by the medical conditions that patients presented.

Now, the initial focus of Wennberg's work and that of other health services research

was not to was not focused on individual physicians nor aimed at helping patients directly.

It's against the same point. The idea was to monitor at a more collective level,

to try to pinpoint practice variation so they could be eliminated by better education.

But here another development intervened to tell to take health services

research in a different direction. The concept of outcomes research

meshed with another key development in the 1970s and early 1980s, namely the growth of the managed

competition movement. As envisioned by the economist Alain Enthoven and Paul Ellwood.

Managed competition would improve healthcare delivery by changing the economic incentives given

both provider and consumer. As Ellwood explained in a landmark 1988 article,

outcomes research constituted, in his words, "a technology of patient experience."

End quote, that could be used to improve healthcare delivery. The managed competition movement became

an important conduit through which the quote, "informed patient informed choice,"

linking entered policy thinking. The growing legitimacy of outcomes

research coupled with the managed competition philosophy created a powerful impetus to develop new

forms of rating and ranking that packed a more direct policy punch.

Here again the initial idea was for analysis by experts, for experts.

But in a post Watergate era, critics of the so-called medical

establishment found themselves with a great bully pulpit to start to

demand more public disclosure of these assessment exercises.

The 1st and most obvious target for this new spirit of disclosure was the

Health Care Financing Administration (HCFA), the government body charged with

overseeing taxpayer funded services delivered through Medicare and Medicaid.

Soon after Medicare's founding in 1965, HCFA

began to set up a national network

of professional review organizations, PRO's, to monitor patient care. By 1973,

their information database was substantial enough to attract the interest of

Public Citizen's Health Research Group. Which tried through congressional

petition and lawsuits to have that data released to the public, but with no success. However,

growing pressures for economic reform and consumer empowerment

eventually breached that resistance. Significantly, the breaching finally occurred

in the Reagan administration. When Republicans committed to the theme of accountability were in

charge of government health agencies. In 1986, then Secretary of Health and Human

Services, Otis Bowen appointed William Roper, described in the William-- The Washington Post as, quote,

"A  public health officer with a strong belief in medical accountability." End quote. As HCFA's head.

Both Roper and his boss were political conservatives as well as physicians who

believed in the accountability ideal. Over the objections of his own staff,

Roper ordered that hospital mortality rates become part of the PRO review process.

Yet he did not intend this report to become public. So he wanted the data reviewed,

but he did not mean for it to be released. However, the New York Times found out

that this review was being done and announced its intention to sue for its

release under the Freedom of Information Act. And at the advice of HCFA's legal counsel,

Roper then released the report in December 1987.

The report received extensive coverage in the news media, with particular emphasis on local

hospitals that got bad grades from HCFA. Observers immediately pointed out

the many flaws of the HCFA data, flaws that hadn't met that had been

the reason that HCFA officials were reluctant to release them in the first place. For example,

the data analysis could not sufficiently correct for how seriously ill

hospitals patient population was. The sicker the patients, the more likely they were to die and thus

to inflate the institutions mortality rates. Yet despite all these problems,

the data release was hailed as a-- this is, again from the Washington Post quote,

"A revolutionary first step in giving consumers an an objective measure of the

quality of care in individual hospitals." HCFA's 1987 release of hospital mortality data

exemplifies a pattern that would recur repeatedly over the next two decades.

Taking advantage of new standards of public accountability, patient advocacy groups and healthcare

reformers found greater support for prying open institutional

databases that had been closed to the Denenberg generation.

With the assistance of newspaper journalist eager and willing to file FOIA request,

the barriers against data release began to weaken. Yet with growing disclosure,

disclosure of information came a predictable cycle of criticism. The data was incomplete.

It was difficult to interpret. These criticisms that would would then lead to redoubled efforts

to redefine data collection. There'd be a new release of data and the same criticisms would be made.

It's not good enough. It's hard to analyze and so on and so on.

Now this is the part of the story that if you hang out much in healthcare services circles you

you've heard nothing I've told you so far is is all that unusual. There is another feature of what

happened in this time period, however, that often gets left out of the

accountability story that is extremely important for us to understand.

And that is the parallel rise during the same decades of market research and healthcare advertising

that formed a counterpoint to this seemingly more objective social

science study of healthcare delivery. The same economic and cultural factors

that led to a growing demand for public accountability also brought about a higher

tolerance for marketing and advertising of healthcare products and services.

The rise of Health Sciences, I'm sorry, Health Services Research,

in the spirit of Donabedian and Wennberg, was accompanied by the equally if not

more robust growth of health services marketing. Although marketing and advertising

were both were by no means new to the American healthcare scene in the 1970s.

Their penetration of the field had been constrained by the resistance both of the

medical profession and the hospital industry. The kind of commercial suasions used to

promote automobiles or appliances were viewed as unseemly when applied to the

public's choice of a doctor or a hospital. But ironically, given the hostility that both consumer

groups and health services researchers had long expressed for the advertising

industry-- was advertising that came along in the 70s to again champion the

idea of consumer rights. As a way to facilitate a widening scope for health

oriented advertising and marketing. As public and private healthcare policy

makers began to experiment with more market oriented approaches to healthcare,

they invested more in marketing and advertising as forms of consumer information.

And they very sincerely believe that that is what advertising information that advertising is.

It's a form of consumer information. And the highly competitive 1980s

healthcare marketplace 'for profit' chains such as Humana and Hospital Corporation

of America spent heavily on marketing, forcing the nonprofit hospitals to respond in kind.

A host of new marketing firms moved into the healthcare field, offering their expertise to hospitals

trying to survive the new competition. Marketing experts enthusiastically

adopted the Information RX, albeit in a forum very different from that

envisioned by Sidney Wolfe or Jack Wennberg. Their information revolution consisted

of better executed advertising and marketing campaigns.

A key part of that effort consisted of helping hospitals counter any unflattering

data that started to emerge from things like HCFA's report cards and

similar quality assessment exercises. Put simply, their job was to buff the

institutions public image. Thus the meetings of the the Healthcare

Academy of the American Marketing Association make for fascinating reading in this regard.

And I can't go into a lot of detail, but I can tell you when you read the accounts

of that group in the 70s and early 80s, they're keenly aware of the dark

side of the era of accountability. For example, as one paper,

one paper in the 1980s talked about how

to deal with bad news and how to deal with

the the sort of move toward disclosure. Given that in their words,

"The healthcare industry is already distrusted in reeling under attack from consumer groups,

employers and Congress." So these two researchers argued in 1988

that outcomes data had to be used very, very carefully, quote,

"To avoid the scenario of hospitals racing against each other on a muddy track

in an endless mortality-data-derby where nobody can emerge as a winner."

To prevent that from happening, they suggested more 'subtle' as they put use of such data,

negative outcomes could be used internally to encourage improvement,

while positive data should be emphasized in public statements and marketing efforts.

By the late 1980s, the massive data dumps from HCFA and the hospital marketing campaigns endorsed

endorsed by what I think of as the other AMA, the American Marketing Association,

had hardly exhausted the demand for reliable, usable information for the healthcare consumer.

Thus, into an already very confused information marketplace, there emerged yet another contender

for the role of the honest broker, namely the mass media.

The trendsetter in this regard was U.S. News and World Report,

which began in 1990 to publish a special consumers guide to hospitals.

The hospital issue copy the formula U.S. News had developed during the 1980s to

produce college and law school rankings. By distilling evidence of an

institution's reputation into an easily comprehensible reading system,

the magazine offered its readers what it called 'news you can use.' The first US News hospital issue

explained why the news magazine decided to enter the business of providing

consumer ratings for hospitals. As the authors noted, hospitals were,

quote, "Prodigious data generators" end quote. Yet with the exception of HCFA's mortality rates,

a data set of debatable value, none of it was in a form truly usable by consumers.

Quote, "Since no medical authority or anyone else had ever devised yardsticks

for rating hospitals that are both useful and statistically valid, U.S.

News had to create its own." To develop its ratings the US News staff sent a confidential

survey form to almost 1500 physicians. In a certain group of

specialties asking them to list the top ten hospitals in their area. It was in essence,

a poll of experts meant to be shared with the public. The survey results were used to winnow

the 6500 hospitals in the United States down to a list of the best 57. As the authors emphasize,

the results quote, "Should not imply that other hospitals cannot deliver

excellent care" end quote, or that the hospitals appearing on the list were always perfect.

But the US News staff felt that their list represented an excellent starting point.

In addition to the list itself, the magazine offered useful advice about

how to assess markers of quality care. Having found a winning formula, U.S. News, stuck with it,

continues to publish the hospital issue to this day. And in effect, the magazine positioned itself as

an honest broker of information upon which readers could depend, and its success soon led to many,

many imitators. Local news outlets began to copy the formula themselves. For example,

monthly magazines and cities began to produce their own hospital issues, like Philadelphia Magazine,

Guide to the Best Philadelphia Hospitals. Best Hospital Lists soon gave

rise to comparable Best Doctors Lists created in similar ways.

And here, New York Magazine's Best Doctors Issue became one of the best known.

Not surprisingly, the disclosure of information about bad doctors

proved to be far more difficult than publicizing lists of good doctors.

In a longer version of of this paper, I have a discussion about the

long battle against physicians, resistance to sharing information

about doctors with malpractice claims and and other problems.

And the the Alliance of Conservative and Liberals that finally broke down that resistance,

resulting in the 1986 Health Quality Data Improvement Act. Excuse me,

which provided for the creation of a national practitioner databank.

The new law required that malpractice insurance companies, state licensing boards,

and other organizations report cases of negligence and incompetence to this databank.

But the law exempted the National Practitioner Data Bank from the

terms of the Freedom of Information Act and limited its use to hospital, state licensing authorities,

and professional societies. So no consumer could use the information. As you might expect.

Public Citizens Health Research Group immediately lodged a court challenge to the law.

The court cited in favor of the physician's right to privacy as

opposed to the public's right to know. But by making such controversy of this,

Public Citizen secured itself access to the databank as well as a seat on

the the databank's governing board. And using that access, the group had began to create

its own bad doctors list, which it it said it published as a service to consumers. Now,

everything I have described to you so far predates the Internet.

All of this happened before the Internet began to accelerate

all of these, all of these trends in the mid 1990s.

I would suggest that in essence, what the Internet has done is speeded up all of the trends

that I've described to you very quickly in the last 45 minutes. But what was true in the 1970s

remains just as true today. What consumer activists, health services research,

health market researchers, and journalists mean by the invocation

of the God Word of information is highly

variable and at times contradictory. From the 1990s onward, the drive to collect more and better

data about healthcare outcomes and it convert that data into consumer

friendly forms has continued apace. The flourishing of commercial forms

of consumer information in the form of sophisticated hospital marking

campaigns and magazine guides has been paralleled by extensive investment

in the public collection and analysis of health related information.

The growing demand for economic discipline, efficiency, cost control,

quality improvement has played an equally, perhaps even more important role.

From an initial focus on hospital mortality rates, these efforts have broadened to

include many other markers of quality care and created yet more expert groups hoping to function as

honest brokers of these databases. And I own, you know, the alphabet soup of NCQA

and and and etcetera, it's you feel like you're back in the New Deal again. Likewise, the consumer

guide concept pioneered by U.S. News and World Report almost 20 years ago

continues to find new expressions. The peer-to-peer evaluation method

initially used with physician opinion leaders is now being used with

consumers as well and hence we come back to Zagat and other companies

who are now going to consumers for information about their own experiences.

Yet for all its proliferation, this deluge of consumer oriented information has not necessarily

produced the results hoped for by its early champions. In the first place

it is an approach to healthcare choice rooted in the needs of

affluent Americans. With the requisite financial and educational resources

needed to 'shop' for healthcare. As critics on the left have long complained,

this kind of consumer driven healthcare system simply perpetuates the

inequitable thrust of the American healthcare system. And in my view this

is an extremely serious limitation on the success of any kind

of consumer information revolution. That said,

even the target audience of middle class educated consumers finds

many of the new consumer oriented information sources hard to use.

Many studies have tested the fact that consumers find rankings and ratings produced by all these

competing groups both difficult to access and hard to understand. More recent rollouts of allegedly

more consumer oriented databases suggest they still have far to go in becoming user friendly,

even for their target audience of the literate and affluent. Patient consumers also complain that

quality measures do not necessarily include the kind of issues that concern them. Look at readers letters

to the New York Magazine's best doctor issue just as a case in point.

Readers complain of its celebrity approach and ask why the magazine doesn't ask what for many

consumers is a critical question, namely, does the doctor accept health insurance?

Others complain because the rankings and rating systems don't tend to focus on mainstream,

as opposed to alternative and complementary medicine. From a policy maker standpoint.

Perhaps the most serious criticism of the rankings and ratings aimed at consumers, though,

is their unintended impact on provider and institutional behavior. The more ratings and rankings

function to quote, "judge and control" in the words of sociologists,

the more they encourage the, again, this is from sociologist "the proliferation of gaming strategies."

As has been shown in studies of law school rankings, awareness of being monitored leads subjects

to alter their behavior in unexpected ways. And a troubling example of this phenomena was

reported in the Annals of Internal Medicine. In 2005, researchers reported that since

New York had begun publicly to report on physicians performance, almost 80% of cardiologists

surveyed reported that they avoided treating critically ill patients

because they feared a bad outcome would affect their scorecard. Predictably then,

given the highly competitive nature both of healthcare provision and mass media,

the proliferation of report cards, ratings and rankings has itself become

a a source of consumer confusion. Consumers now require guides

to the guides and and again in a library setting, you know what I'm talking about.

You have to know what are the acceptable versus the

unacceptable websites to be used. MedlinePlus being devised precisely

to to help consumers read through

information about disease conditions.

And if you look at the the Medical Library Association's Consumer health section,

you see that the the list of criteria that it has to use to judge whether or

not to to allow a website on to one of its top 100 list includes credibility,

sponsorship, authorship, content, audience currency, disclosure,

purpose links, design, interactivity and caveats. If history is any guide,

the cycle of more consumer information sources followed by more questions

and more criticisms will likely continue unabated in its future. Many different groups will continue

to vie for primacy as the consumers Trusted Guide to Healthcare Information.

Marketing firms will continue to spend quality information into

advertising plans to benefit their clients. Healthcare institutions and providers

will continue to try to game the rating system to try to improve their report cards.

Sophisticated health consumers are going to have to realize that all, not not all,

ratings and rankings are equal. As this historical overview suggests, Better information sources for

health consumers have not turned out to be the magic bullet capable

of correcting the dysfunctionality of the American healthcare system. The limitations of the Consumer

Information RX reflect the fact that this consumer information revolution

has been inseparable from the broader marketization of healthcare that

has occurred over the last 50 years. Information itself has become a commodity,

produced and circulated by many different actors. What sounds good in theory,

better information leads to better choices has proven difficult in practice,

while it has been productive of much good. And let me hasten again to say

I'm fully in support of of of the idea of the informed consumer. The consumer health information

has not resulted in a remarkably more efficient healthcare system. Not that that's all to be blamed

on the consumers either. But not the least of these, the reasons for this failure is

the fact that American Healthcare is delivered within such a highly competitive and market oriented culture.

For which for many players, information is simply another word for advertising.

Yet we do not want to throw the baby out with the bathwater, as Arnold Epstein,

the physician who heads Harvard's Department of Healthcare Policy and Management wrote.

Even if patients find new quality report cards hard to use, quote, "shedding sunlight on medical

practice is unquestionably healthy medicine for patients." While flawed in many ways,

the consumer health revolution has become a policy fact of life in the United States.

There is no returning to the pre 1970s era in which information and accountability did not figure

as goals of policy making. Rather, the key to a better future lies and

having a more realistic understanding of what informed consumers can and cannot accomplish.

Thank you.

[Coughing]

[Applause]

[Elizabeth Fee:] Thank you, Nancy, for such a impressive and very relevant [Giggling]

presentation and lively as well. We have time for questions and answers.

But just before we start, I wanted to invite all of you to join the Washington Society

for the History of Medicine. I have some membership forms here.

It's a very good value. Standard membership is 15 dollars, $10

if you're a student. I'd like someone to help me pass these around. Maybe David [?]

Thank you so much.

[Footsteps]

[Unintelligible]

[Cough]

[Elizabeth Fee:] And now let me, I'm sure there

are many comments and questions, but if you have a comment or question,

please press the little button. Most of you have a microphone in front of you so that everyone

will be able to and lean into the microphone so that everyone including

those of us who are hard of hearing can can hear your question.

Thank you. Questions, comments. Yes.

[Audience:] Hi Doctor Tomes, thank you very much.

Just to distinguish these were these were ratings and rankings covering for

the most part doctors and institutions rather than research based information

per se, is that is that right?

[Nancy Tomes:] Yes. So I'm I'm looking more at the

again it's a it's a subset of consumer oriented tools mostly about the choice,

choice of hospital and choice of doctor. [Audience:] It's interesting because part of what

we're struggling with when we're trying to get research based health information

out to the public is finding some reliable measures well in the federal system.

I mean finding with some reliable measures that that we we can use.

I mean we saw a report I guess it was about a month ago that that correlated

increase in NIH funding with improve some some improvements in certain diseases.

Of course there was a time like you you saw that report yeah and but you know

it's it's kind of a long way to to wait. So do you, do you know of any historians that are

covering or or any sociologists that are covering this this particular angle?

[Nancy Tomes:] It seems like it's more in terms of specific diseases. I'm looking at David here.

He's not looking at me, but it I think that kind of that now he's like waking up,

but it tends to be more in terms of a specific condition to look at what's

the interplay between more research, dissemination of research information and

then trying to see some positive outcomes. That it's such a big topic to try

to do for all of medicine that it tends to get focused more in on a particular set of conditions,

like cancer for for example, which of course turns out to be incredibly complicated because

it's so many different diseases. But I, you know, I share your sense of of, again,

something that sounds like it should be simple and easy. It's extremely difficult.

And even coming up with criteria can involve, you know,

enormous intellectual and political debates. [Audience:] It's just an you think that's

just the nature of the beast? --Yes. And the first it is. --I think it is just the nature of the beast.

--Yeah. Thank you.

[Elizabeth Fee:] Others, Yes, we have two over here. Ladies first. Thanks.

[Audience:] I was very interested in the aspect of your talk which talked about using

these guides for political purpose, I suppose ideological means. And I was thinking back that perhaps

one of the early routes to this would have been some of the guides published

by activist women's organizations, yeah, guides to doctors who would

provide abortions and things like that. And they had that sort of particular

idea that these guides were kind of recasting the power relationship

between the patient and the doctor. Do you see that as being a particular

period within the history of these guides,

or do you still get a sort of sense of an

ideological sort of purpose to these now? Was it really just about

a right to information? [Nancy Tomes:] Let me say first in response that

the Women's Health movement in the 1970s was an enormous part of the

push that that led to the opening up, you know, probably the first among many of

the patient advocacy groups that

made this better information to equalize what had been

an unequal relationship. In terms of the tone issue,

there is a dramatic moderation if you look at the 1960s,

late 1960s, early 1970s and

then into the mid to late 1970s,

definitely a a toning down and this,

you know, reflects a a lot of the

the changes from the 60s to the 70s.

But I'm in many ways the core of the argument that the the more

radical voices we're making in the 60s moved into the mainstream rather

than becoming totally domesticated.

And yet what what I think when you

take that argument away from a larger call for change, social change,

that it then becomes much more of a focus on individual responsibility

and information instead of a more collective exercise. That's good.

Good question. Yeah.   [Audience:]  I understand that the US and New

Zealand are the only two countries that permit direct to consumer advertising of, --that's correct,

--prescription drugs. I think that our commercial television is

probably now drug dependent and I wonder

how our situation compares with most other countries in terms of this information? Do you--

[Nancy Tomes:] It's that's a parallel interest of mine and in

fact I have a whole other talk on the history of direct to consumer

advertising and why the historic limitations on that also disappeared

again in in the 1980s very similar to what I described today about

the ratings and and rankings. The question of what the long term

impact is is a very interest, interesting one and they are now people.

There's that essentially making careers out of studying direct to consumer

advertising and its impact on the people who who hear it and

how it's changed the patient provider

relationship. Which is very interesting.

But my sense from from reading the

policy literature is that it doesn't matter what is going to be shown in the

effect of direct to consumer advertising.

Once a form of advertising is allowed, it's virtually impossible to put

the genie back in the bottle. So that whether we like it or not,

we are we're going to be stuck with it. Best case scenario is more limitations

on what it can say, when it can be, what can be advertised at particular points in time.

But my, at this point, my sense is it's here to stay and that we will learn to tolerate it

the same way that our grandparents learn to tolerate patent medicine ads,

you know in the 19 teens.

[Background chatter]

[Audience:] Yes, hello. I'm wondering if you could elaborate a little bit more of

the Zagat-Wellpoint partnership and what was the market response beyond

the initial press releases and or any prescriptions you have for Wellpoint or

other insurers in light of your research.

[Nancy Tomes:] That's a, it's a good question and it's almost too soon

because I perhaps should have made clear you can't get this information.

You can only see it if you're a Wellpoint subscriber. So it caused an enormous hoopla,

but in fact it's not in some ways as significant as the online the

services that you can that you can access regardless of of what

what provider insurance you have.

The the project was just started in

December 2008 and it's you know July 2009.

I kind of I'm limited to what I can see on LexisNexis and so far nothing has cropped up yet.

I'm sure internally there's a lot more going on there, but they don't,

they don't share that for some reason they they to to folks like me lurking.

So maybe a year from now I'll be able to give you a better answer.

[Audience:] Can I follow up? Looking at your research though, do you see, is there anything that

jumps out more generally about the role of the health insurer as the provider of the guide information,

either positively or negatively? [Nancy Tomes:] That's a good question.

That's something I really need to think more about, positive or negative, probably some of both.

Because essentially health insurers have

a strong incentive to create a system where you use less care more effectively.

So I for, I'll use my own healthcare plan. I'm an employee of the state of New York.

They have a vested interest in helping me manage, you know, what health problems I have.

So I use less healthcare. And so educating me,

getting me hooked up with the, you know, most cost effective kind of treatment

is definitely in their best interest.

If you're not sick and don't have a serious illness that needs to be managed,

I think that you know that can work reasonably well, hasn't proven a big problem for me.

I think when when the difficulty comes along is when you are really,

really sick and all of a sudden

it's not the minimal cost effective

whatever that they become less helpful. But that time I'm not telling you

anything you don't probably already know. So I'd say mixed.

Mixed as as most of these relationships are, it's some good and some bad

mingle together. And some insurance companies are better players than other insurance companies.

[Audience:] I wonder if there's any pushback against this model of gathering information

and spreading it either on the basis that Healthcare is not fall into the

consumer model quite so easily or that the data themselves are so complex

that any simplification is really misleading.

[Nancy Tomes:] Both and that, again, that's a good question.

I'm kind of showing you what so far has been a pretty much unstoppable trend toward disclosure.

But at every step of the way, there have been people who've said

choosing a physician is not like choosing an automobile.

That in fact that argument goes back to the 1920s. Well, when we first got automobiles,

people were saying choosing a doctor is not. In fact one of the things I've learned

in my study is just how many of the the problems we're grappling with have

have been around a lot longer than than I knew before I started this. So questioning the consumer,

the other commodification of

healthcare and the use of of techniques

developed for breakfast cereals and you

know radios and automobiles are very

definitely a strong pushback against this, this, this way of thinking.

And the other argument about that the data is too complex to really

be able to use in this way is also an undercurrent in in all of these

moves forward that people are saying it's not something you really

can reduce to to a report card.

But we still have report cards. So, you know,

I think there's some kind of balancing there of of something important that

this is providing for at least some people. Not not me, I have to admit.

I'm not not someone who's been going and spending a lot of time looking up report cards,

especially after reading all the US News. The law school stuff is true is really disillusioning.

The other thing is, I don't know if any of you are academics.

You know there's a rate yourprofessor.com and let me tell you,

all you have to do is think about what shows up about you on those and you're like, OK,

maybe these report cards aren't such a good thing.

Because it does create a platform for people,

you know, who have their own particular crotchets to to go on and on.

So the good and the bad mingled together. Yeah.

[Cough]

[Audience:] I heard a story on NPR a few weeks ago about physicians who were asking their

patients to sign agreement that they wouldn't rate the physician. -- (gasping) Really.

The reason being that physicians are held by the HIPAA laws and can't

refute anything that's said about the care of the patient or the situation. And I'm just curious

if you have any thoughts on that? [Nancy Tomes:] I had not heard that. So now, thank you.

I have to go back and look at NPR. That's a kind of. It's the first time I've heard

HIPAA brought into the discussion of the the doctor ratings though.

So thank you I'll I'll try to find out more about that. I don't mean to be cynical

but a lot of the I mean

I can well imagine a physician has some very good reasons for really not

not wanting to participate in this. But so much of in the 1970s of the

you know the use of the ethics was

to try to shut down information that consumers are trying to get

that that maybe I think from our standpoint office hours you know it

would seem like that that shouldn't have been such a such a big deal.

So but anyway I'll see if I what I can find out about that very interesting.

[Elizabeth Fee:] I wonder, is there a physician in the room who'd like to comment?

[Nancy Tomes:] Yay, Rob, Rob will say something.

[Laughter]

[Question off microphone]

[Rob:] Yes. One is the movement

within the medical boards is [?]

[Question off microphone]

[Nancy Tomes:] And that varies by state-by-state, yes.

[?]

Advocates within the regulatory body. So the transparency,

professional boundary issues, yeah, that's happened. Yeah. And some states,

they quite actively rely on violence. So that's one thing. And the

other thing, if you comment on the varieties of speech on the

[Question off microphone]

[Nancy Tomes:] Indeed. --Standards of speech. --Yes,  and--

I'll start with the second point first.

I think the one of the insights I've

gotten from my historical research is the

importance of the trusted intermediary and that the when I think about the

implications of this for myself, it's in the learning to distinguish.

Someone who I think is giving me information

without having a direct financial payoff. Learning how to distinguish the good

from the bad and and again those of you who deal with any kind of Internet

or or you know any sort of education today teaching our students that

not everything on the Internet is correct and that you have to learn

like like what what to look for. And it's not it. It probably wouldn't be the same

for me as it would be. You know I'm going to have specific things that are going to be

my markers for authenticity that you know other people might not share.

But the developing of that awareness

and taking the trouble to familiarize yourself with some criteria of

what's good and bad information. I think it's really that's the trend of of

of the future that that we're going whoops, that we're going to going to see

more of.  The question about the practitioners databank that that

really is something that fascinates me. That's going to take, I think, a whole another paper.

Because looking at the legal issues there in terms of the disclosure

of information about lawsuits that

providers have been involved in, it's been an extremely contentious

area of the law. And the point you're making about the variation at the state level is

something else that I've become very aware of in doing this research. I think naively I thought there

was an not not being a physician, I would would think this that there

there is some kind of uniformity that there's some sort of national code for whatever. No way,

just looking at all kinds of public health related regulations

that state variation is enormous. So living in New York,

I have a different set of resources available to me than if I lived in Kentucky or Idaho or whatever.

So it's a very,

very important point and the whole

physician databank is something that I would really, I'd like to to get into more. Seriously.

[Rob:] I have a follow-up.

[Elizabeth Fee:] We have one follow up and then one go ahead.

[Question off microphone]

Oh yeah, yeah, yeah, absolutely.

[Question off microphone]

[Gasping]

[Question off microphone]

Right, exactly. Yeah. I'd have to say in my,

you know my gut level of what is not

working about that. In the direction

that we've headed in this country is very

much that point that we have reified a

model for decision making that is based on.

A minority of what normal people can do and

that then blaming people because they cannot. They don't have the time to do

all this extraordinary. I mean, it just makes me tired to read about it. You don't have the time,

you don't have the money. It's it. I think it's just a really there's an

inequity there that that doesn't get enough attention. In part because we

you know where I think Americans have a love affair with information they

think it's a solution to everything. And you know you're you're sort of

considered a bad actor for saying but you know information is is not

as easy for some people to come by at least in this particular form. So I'm really I too see that

as a very big issue.

One more back there. Yeah, Hi.  [Audience:] I was just wondering when and where

will you be publishing this research? [Nancy Tomes:] I have to ask because since David B

has gone off to be Obama's advisor,

it's supposed to be coming out with Rutgers University Press and it's part of a whole volume where

physicians and sociologists all look at information technology. It's a, it's a terrific book,

but I don't know what they're doing now. I guess they wrote us a little

note and said good news is that, you know, our David is going, you know, to to be the advisor.

The bad news is it's going to slow down the publication. But if you'll send me an e-mail,

I can, you know, let you know. I actually need to ask them what's going on

as well because it's a timely subject.

So we'd like like this to get out there.

Yeah.

What's your e-mail address?

Oh, come. Come in and I'll go see. I probably have a card. I'll give you my card. OK.

Yes, I'm sure that should be. You can Google me too. Yes. You've been a great audience.

Thank you. Great questions.

[Elizabeth Fee:] We're going to thank all of you for your participation. Thank you.

[Applause]