A different version of this article appeared here in the Library of Law and Liberty.
The U.S. healthcare industry is notoriously inefficient and troublesomely massive. It’s also wealthy and getting wealthier and more powerful as medical costs have exceeded, by some estimates, $10,000 per person.
What’s to be done?
Back in 2005, a group of healthcare experts asked, in a RAND Corporation study, whether electronic medical-record systems could transform healthcare by reducing costs and increasing efficiency. The answer, in short, was: it depends.
Although systematizing electronic medical records could save over $81 billion per year, these potential savings would be realized, the study concluded, only if healthcare in the United States integrated new technologies to allow for the flow of medical data between the patient and relevant parties such as doctors, hospitals, or insurers. Non-standardized record systems would result, by contrast, in inconsistent, inefficient, and incomplete data exchanges that could increase rather than decrease costs.
RAND Corporation revisited the issue in 2013, finding that healthcare expenditures had grown by $800 million since 2005 in part because systems of electronic medical records remained non-standardized. “We believe that the original promise of health IT can be met,” wrote Arthur L. Kellermann and Spencer S. Jones, the authors of the study, “if the systems are redesigned to address these flaws by creating more-standardized systems that are easier to use, are truly interoperable, and afford patients more access to and control over their health data.”
Healthcare in the United States is constitutionally fragmented: Not only does the industry consist of various entities, from doctors and hospitals and insurance providers to commercial suppliers of devices, goods, and services, but also the pricing of medical services is unreliable and unpredictable in part because the country is so large and the industry subject to different regulations from state to state.
Information integration could go a long way towards cutting medical costs and increasing medical savings. For example, it could reduce waste resulting from misdiagnoses, repetitive procedures, erroneous prescriptions, and duplicate testing and imaging.
What if there were a simple solution for this waste?
One entrepreneur believes he’s found the technology to revolutionize the way healthcare records are shared and maintained through Health Information Exchange (HIE).
Robert E. Higgs is the founder of ICUcare, a company that aims to improve technologies in the fields of telemedicine and electronic health records. He has invented a “smart” health card that can contain a patient’s complete medical history, which is stored in a cloud. His vision is that patients own their personalized smart cards, which they can voluntarily submit to healthcare providers and institutions for cheaper and more efficient services. Data on the card are easily stored and updated and exchanged only with the patient’s consent; thus, in the case of emergency, the patient’s medical records can be readily accessed and quickly reviewed.
There remains, sadly, a felt need to transition the healthcare industry from paper to electronic records. The smart card meets this need, but it does much more. It tracks your billing history, reconciles erroneous payment information, protects against fraud and identity-theft, and serves as a conveniently portable device.
One would expect such a card to have been in circulation by now, given the extensive government investment in HIEs. President George W. Bush, for example, issued an executive order in 2004 to create the Office of the National Coordinator for Health Information Technology (ONC), a division of the Department of Health and Human Services (DHS) designed to advance technology and innovation pertaining to the exchange of healthcare information. This office created eHealth Exchange, a coalition of states, federal agencies, hospitals, medical groups, pharmacies, and other such entities that’s now run by the Sequoia Project.
But the federal government and the public-private partnerships it has fostered have been unable to produce a smart card that matches Higgs’s in capability and functionality. And even if they had, government retention of sensitive medical data would, among other things, raise privacy concerns that voluntary private transactions and coordination would alleviate.
Moreover, the many spinoff organizations emanating from the ONC and DHS have only crowded the field with swollen, inefficient government and quasi-government structures and programs. Rather than helping the situation, these putative “solutions” have slowed down innovators like Higgs, forcing them to deal with politicians and bureaucrats rather than patients and hospitals.
Having heard about Higgs’s curious smart card through a friend, I decided to reach out to him to find out more. I asked him, first, about privacy implications, namely whether the smart card could increase incidents of non-consensual data transfers and disclosures.
The smart card, he said, “never sends data to the care provider—it brings the care provider to the data.” He explained that data on the smart card are encrypted using the same standards as those used by the Department of Defense for common-access cards.
“We used Advanced Encryption Standard 265, or AES-256,” he said, “the highest standardized encryption specification that’s used worldwide by entities as diverse as corporations and the U.S. government. The key size of 256 bits means that the key, which turns encrypted data into unencrypted data, is a string of 256 ones or zeros.”
I admitted that I didn’t fully understand.
“Put it this way,” he said. “The research I’ve read indicates that each character has two possibilities—one or zero—for which there are 2,256 possible combinations. If 50% of the possibilities must be exhausted to determine the correct key, then you need to guess 2,255 of them [to hack the encryption].”
Pressed about how long it would take to test all possible keys to break the encryption, Higgs, parroting a claim I’ve heard used to describe bitcoin, said, “The universe itself has existed for 14 billion years. It would take something like 1.5770813e18 longer than our universe’s full age to exhaust just half of the key-space of our encryption.”
An attempt to verify Higgs’s figures turned up a plethora of studies and blog posts about encryption and decryption, bitcoin, hacking, and computer engineering (the calculation appearing on many blogs and tech sites is ~6.7e40, which equals 235,385,265,247,008,100, which is multiplied by 6.7 to yield the 1.5770813e18 number that Higgs supplied).
These calculations can be confusing, but the point Higgs wanted to drive home is that the smart card reverses the current power imbalance: today corporations and governments store medical records that patients often can’t access or don’t know about; the smart card, however, empowers patients to store their own records that they may voluntarily release to corporations and governments. The smart card, in other words, returns agency to the consumer whose data is at stake.
It would also, Higgs alleges, reduce rates of healthcare fraud. According to estimates by the National Health Care Anti-Fraud Association, the United States loses tens of billions of dollars every year due to healthcare fraud. Canada, Germany, and France have each instituted some form of a smart card to successfully cut back on fraud.
A company called Cerner has just landed a deal with the Department of Veterans Affairs (the VA) to implement an electronic health records system. The move away from the VA’s Vista system to Cerner’s electronic system suggests that at least some government officials are aware of the need to adopt interoperable and integrated measures of retaining and sharing medical records. The VA will implement the same electronic health record system used by the DOD.
So far as I can tell, however, Cerner has not created a smart card like Higgs’s. I reached out to Adam Lee, a senior communications partner at Cerner, to ask about smart cards and Cerner’s hopes and plans with the VA. Lee referred me to this press release about Cerner’s work with the VA but did not discuss smart cards.
Talking to Higgs is like talking to a computer: more engineer than salesman, he’s strikingly intelligent but has difficulty getting through to politicians. He’s monotone and meticulous, frank and unexcitable. He’s fast with facts and figures and savvy with technology, but the average politician wants to know primarily whether the smart card appeals to constituents and only secondarily whether it’s operable and efficient.
Higgs grew emotional during our phone call, however, as he told me the story of his wife, who underwent a routine procedure that went wrong. He claimed that, during this standard operation, errors were made that could have been avoided had her doctors possessed his wife’s proper medical records. She’s been subjected to numerous tests throughout her illness, he said, only to have them redone when visiting a new facility or specialist because of an inability to simply retrieve her medical history. She remains in bad shape, living at home with hired assistance.
This unfortunate situation has motivated Higgs to seek answers to save others from similar mistakes in similar circumstances.
If Higgs’s smart card is so great, you might ask, why hasn’t it been adopted? Why haven’t I heard of it? Why doesn’t it circulate widely? Why aren’t hospitals jumping at the opportunity to use it?
The answer, according to Higgs, is simple: the healthcare industry doesn’t want you to know about his smart card because it doesn’t want to reduce costs. It’s full of people getting rich off inefficiency and artificially high prices. Lobbyists for the healthcare industry have taken advantage of the fear and apathy of politicians to ensure that technological progress is delayed or stymied.
Thus, Higgs describes his job in terms of David versus Goliath.
There are numerous ideas about how to trim healthcare spending; Higgs’s smart card is not the exclusive remedy or sole fix. But it’s an encouraging development. Healthcare spending makes up about 17.8% of the nation’s economy, according to an actuary report by the Centers for Medicare and Medicaid Services. And it shows no signs of decreasing. This trend is unsustainable; something must be done—and undone.
We could use more men like Higgs and less government to push us in the right direction before it’s too late.
AM: Thanks for discussing your debut novel with me, Anton. It’s titled Al-Tounsi and involves U.S. Supreme Court justices who are laboring over a case about an Egyptian detainee held on a military base in the Philippines. How did you come up with this premise for a novel?
AP: I was interested in the intersection between contemporary legal and political issues and the personal lives of the justices. I was particularly impressed by the ways in which the writ of habeas corpus has been used (and suspended) throughout U.S. history.
The Great Writ is a heroic call to responsibility—a demand made by the judiciary for the executive to live up to its obligations to imprisoned individuals. While it has obvious political and social ramifications, it also has philosophical ones. It encourages moral and psychological reckoning: what are our responsibilities to others?
I was excited about writing a novel where two strains—the political and the personal—overlap and blend. I realized that if I fictionalized the important 2008 Guantanamo Bay case Boumediene vs. Bush—by changing key events, decisions and characters—I could use it as the basis for a novel about the Court that explores all my interests.
Anton Piatigorsky
AM: How did you decide to change directions and write about the law? Did this case just jump out at you? Your previous writings address a wide variety of subjects but not, that I can tell, law.
AP: I came to the law, strangely enough, through religion. I’ve long been interested in how religion functions, and especially in the ways that secular systems mimic religious ones. When I started reading about American law and the U.S. Supreme Court, I saw those institutions as a part of an Enlightenment era secular religion. From this perspective, law is a system of rituals, codes and writings that helps establish an identity for a community, a set of shared values and beliefs, and a way for people to function within the world. I found that fascinating. It inspired all sorts of questions.
What are the general beliefs about people and the world that lie beneath the American legal system? How are those beliefs enacted in cases, courts, and legal writings? How do they play out in the rituals of the Court? How do the justices of the Supreme Court —who are, in some ways, high priests of the legal world — reconcile conflicts between their personal beliefs and the foundational beliefs of the legal system they guide?
The fictional stories I wanted to tell about justices’ lives grew out of these general questions. Those questions also led me into an investigation of the main case before them.
AM: One of the most fascinating parts of the book, to me, is the Afterword, which consists of the concurring opinion of the fictional Justice Rodney Sykes.
AP: I have always loved novels of ideas, when a character’s emotional journey overlaps with their complex thoughts and beliefs. Whenever that type of fiction really works — as it does with Dostoyevsky’s The Brothers Karamazov — the character’s philosophy or worldview stands alone as a work of non-fiction. And so the novel becomes part fiction, part critical thought. It functions as a critique on ideas that circulate in the real world.
That’s what I hoped to achieve for Justice Rodney Sykes’s formal opinion in the novel’s Afterword. I wanted Rodney to reach a powerful critique of basic tenets of the American legal system. I wanted him to address what our responsibilities are (or aren’t) towards others in the legal system, and the problems with that system’s fundamental faith in individual actors. In his concurrence, Rodney takes an unorthodox and unlikely stance for a Supreme Court Justice, but that’s what makes it a work of fiction. A novel can be the perfect forum to discuss how a real person might come to a radical decision, and how that decision might revolutionize their thoughts and actions.
AM: Who are your favorite living writers?
AP: I particularly admire J.M. Coetzee and Alice Munro. I think about their works often while I’m writing and editing my own.
Coetzee has written several fantastic “novels of ideas.” Both Diary of a Bad Year and Elizabeth Costello manage to incorporate far-reaching critiques into their larger stories about characters, and they do so while using imaginative formal techniques. I also love Coetzee’s cold and austere style in his less overtly intellectual books. They’re cleanly written, shockingly honest, and endlessly compelling.
Alice Munro—although it’s almost a cliché to praise her at this point—shows remarkable insight into her characters, gradually revealing their motivations, resentments and surprising decisions without ever erasing their fundamental mysteries as people. Her stories are complex formally, but in such a quiet way that I often don’t notice their structures until I’ve read them a few times. Her writing is a great model for how to show characters’ lives and decisions with efficiency and imagination while maintaining mystery.
AM: Do you intend to continue in the novel form in your own writing?
AP: Absolutely. I would love to write more legal fiction, as well. I’ve spent years learning about the law, but know that I’ve barely scratched the surface. There are so many potentially interesting legal stories. I’m also at the early stages of a new novel, which is not explicitly about law, but does feel like an outgrowth of Al-Tounsi in certain ways.
AP: It must be fascinating to work on the diverse cases that roll through a court. I can only imagine how many potential stories you and other lawyers, judges and court workers can recall—ideas for a million novels and movies and plays.
I think legal stories are particularly exciting for fiction because they distill big questions into concrete human situations and personalities. The giant subjects of guilt and innocence, love and betrayal, responsibilities towards others as opposed to ourselves, community or self-reliance, greed, jealousy and ambition all play out in specific facts and events, in the concrete details of a case. It’s just like in a novel. And since the American legal system is, in my mind, an application of an entire Enlightenment, philosophic worldview, these test cases and stories also pose huge philosophical, ethical and moral questions. It’s no coincidence some of the best novels ever written involve detailed legal plots.
AM: That reminds me of something Justice Holmes once said: “Law opens a way to philosophy as well as anything else.” But it sounds as if you and I would go further and say it might open a way better than many other things do.
AP: Law is like applied philosophy; It puts general ideas to the test in the real world. If a philosophy remains theoretical it never really touches what it means to live it, inside it. The answers theoretical philosophy provides are always tentative.
A huge inspiration for my novel was the work of the late French philosopher, Emmanuel Levinas. While Levinas’s writing is often arcane and difficult to get through, I find his thinking to be a powerful and searing indictment of basic Enlightenment principles. While I was writing Al-Tounsi, I used Levinas’s insights—directly—to help me construct Justice Sykes’s final concurrence. It was hugely inspiring to find a concrete way to use this philosophy I have long loved. All the questions and problems I was interested in exploring were present in this genuine legal situation, in the constitutional habeas corpus case, Boumediene vs. Bush, on which I based my fictional case of Al-Tounsi vs. Shaw.
So, yes, I completely agree with you and Justice Holmes!
AM: So glad we had this opportunity to talk. Let’s do it again.
The Literary Lawyer: A Forum for the Legal and Literary Communities 