As a practicing physician I have long been frustrated with the Electronic Health Record (EHR) system the federal government required health care practitioners to adopt by 2014 or face economic sanctions. This manifestation of central planning compelled many doctors to scrap electronic record systems already in place because the planners determined they were not used “meaningfully.” They were forced to buy a government-approved electronic health system and conform their decision-making and practice techniques to algorithms the central planners deem “meaningful.”  Other professions and businesses make use of technology to enhance productivity and quality. This happens organically. Electronic programs are designed to fit around the unique needs and goals of the particular enterprise. But in this instance, it works the other way around: health care practitioners need to conform to the needs and goals of the EHR. This disrupts the thinking process, slows productivity, interrupts the patient-doctor relationship, and increases the risk of error. As Twila Brase, RN, PHN ably details in “Big Brother in the Exam Room,” things go downhill from there.

With painstaking, almost overwhelming detail that makes the reader feel the enormous complexity of the administrative state, Ms. Brase, who is president and co-founder of Citizens’ Council for Health Freedom (CCHF), traces the origins and motives that led to Congress passing the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. The goal from the outset was for the health care regulatory bureaucracy to collect the private health data of the entire population and use it to create a one-size-fits-all standardization of the way medicine is practiced. This standardization is based upon population models, not individual patients. It uses the EHR design to nudge practitioners into surrendering their judgment to the algorithms and guidelines adopted by the regulators. Along the way, the meaningfully used EHR makes practitioners spend the bulk of their time entering data into forms and clicking boxes, providing the regulators with the data needed to generate further standardization.

Brase provides wide-ranging documentation of the way this “meaningful use” of the EHR has led to medical errors and the replication of false information in patients’ health records. She shows how the planners intend to morph the Electronic Health Record into a Comprehensive Health Record (CHR), through the continual addition of new data categories, delving into the details of lifestyle choices that may arguably relate indirectly to health: from sexual proclivities, to recreational behaviors, to gun ownership, to dietary choices. In effect, a meaningfully used Electronic Health Record is nothing more than a government health surveillance system.  As the old saying goes, “He who pays the piper calls the tune.” If the third party—especially a third party with the monopoly police power of the state—is paying for health care it may demand adherence to lifestyle choices that keep costs down.

All of this data collection and use is made possible by the Orwellian-named Health Insurance Portability and Accountability Act (HIPAA) of 1996.  Most patients think of HIPAA as a guarantee that their health records will remain private and confidential. They think all those “HIPAA Privacy” forms they are signing at their doctor’s office is to insure confidentiality. But, as Brase points out very clearly, HIPAA gives numerous exemptions to confidentiality requirements for the purposes of collecting data and enforcing laws. As Brase puts it, 

 It contains the word privacy, leaving most to believe it is what it says, rather than reading it to see what it really is. A more honest title would be “Notice of Federally Authorized Disclosures for Which Patient Consent Is Not Required.”

It should frighten any reader to learn just how exposed the personal medical information is to regulators in and out of government. Some of the data collected without the patients’ knowledge is generated by what Brase calls “forced hospital experiments” in health care delivery and payment models, also conducted without the patients’ knowledge. Brase documents how patients remain in the dark about being included in payment model experiments, even including whether or not they are patients being cared for by an Accountable Care Organization (ACO). 

Again quoting Brase, 

Congress’s insistence that physicians install government health surveillance systems in the exam room and use them for the care of patients, despite being untested and unproven—and an unfunded mandate—is disturbing at so many levels—from privacy to professional ethics to the patient-doctor relationship. 

As the book points out, more and more private practitioners are opting out of this surveillance system. Some are opting out of the third party payment system (including Medicare and Medicaid) and going to a “Direct Care” cash pay model, which exempts them from HIPAA and the government’s EHR mandate. Some are retiring early and/or leaving medical practice altogether. Many, if not most, are selling their practices to hospitals or large corporate clinics transferring the risk of severe penalties for non-compliance to those larger entities. 

Health information technology can and should be a good thing for patients and doctors alike. But when the government rather than individual patients and doctors decide what kind of technology that will be and how it will be used, health information technology can become a dangerous threat to liberty, autonomy, and health. 

“Big Brother In The Exam Room” is the first book to catalog in meticulous detail the dangerous ways in which health information technology is being weaponized against us all.  Everyone should read it.