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If I had to boil down my healthcare technology worldview into one sentence, it would be this: "The technology shows great merit, but financial and other political issues remain." Time and time again, we see examples of how technological innovation is hindered by the financial question of who should pay for it. The industry has done a great job of promoting the development of high-end imaging equipment, but that's in part due to payers' willingness to ante up for the procedures.

IT is a different story, however, and the jury is still out on who should rightfully bear the burden of implementing the technology everyone says the industry so desperately needs. With physicians, this issue surfaces frequently. They say, rightfully, that everyone else (read: payers, employers, pharmacies, even patients) stands to benefit if a provider organization automates its clinical documentation. So why shouldn't they pay for it?

This economic conundrum came up during a telemedicine seminar I attended at last fall's conference of the American Medical Informatics Association. The presenters discussed how various telemedicine applications that connected patients and clinicians--sometimes across large geographic regions--worked, and worked well. For example, a program in Oklahoma improved outcomes and avoided hospitalization costs for wound care patients. Based on videoconferencing, the system brought together physicians, nurses and educators. Another project in Rochester, NY, enabled children at remote locations to get pediatric consults without leaving school. That's a winner for the kids and their parents, who may avoid ER trips or skipping work to cart Susie to the doc.

Both projects were sparked by federal grants. But as the grant money runs out, their future remains unclear. To create an economically sustainable business model, the technology would need to be supported by payers in the same way that imaging is. And even if it were, other questions would arise about how the pie should best be split among the participating clinicians. Collaboration across formerly competing organizations is great, but people still need to get paid. That's why, in preparing my list of questions before interviewing a source, I usually add a very brief one: Who pays? It's a simple question. But it can elicit a remarkably complicated response--or none at all.

-Gary Baldwin

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