McGrath, Robert J.

English

UNH Scholars' Repository

University of New HampshireUniversity of New Hampshire Scholars' RepositoryThe University Dialogue Discovery Program2010When is a lot still not enough? health information,the public good and privacy rightsRobert J. McGrathUniversity of New Hampshire, robert.mcgrath@unh.eduFollow this and additional works at: https://scholars.unh.edu/discovery_udPart of the Health Communication Commons, and the Health Policy CommonsThis Article is brought to you for free and open access by the Discovery Program at University of New Hampshire Scholars' Repository. It has beenaccepted for inclusion in The University Dialogue by an authorized administrator of University of New Hampshire Scholars' Repository. For moreinformation, please contact nicole.hentz@unh.edu.Recommended CitationMcGrath, Robert J., "When is a lot still not enough? health information, the public good and privacy rights" (2010). The UniversityDialogue. 61.https://scholars.unh.edu/discovery_ud/61When is a lot still not enough?Health information, the public good and privacy rightsRobert McGrath, Ph.D.Assistant Professor of Health Management and PolicyThe United States health care system is the largest in the world.  With annual spend-ing approaching 2.3 trillion dollars in 2009, it eclipses the entire gross domestic product of many other countries. Yet unlike many other industrialized nations, it is a fragmented system that relies primarily on pri-vate markets for its provision. This reliance has led to similarly fragmented information about the health of individuals that in turn limits in some cases even a cur-sory understanding of the health of the population as a whole.  Many have argued that some form of collective health information about the population is imperative to the betterment of society, and have called for uniform data collection that links health, socio-economic indica-tors, indicators of health risks and the like so that future interventions might be better targeted most effectively. Yet others believe that such mandatory data collection is a violation of personal privacy and the basic rights of American citizens. The question remains: what level of information gathering is the appropriate one, and is health information collection possible that serves the public interest while still respecting the privacy of patients and citizens?Health Information and Privacy:  A Brief HistorySince the early days of organized medicine, physicians and other providers have collected, stored, and uti-lized health and personal information to better care for patients. The recording of health histories, presenting symptoms, and other clinically related information has been a long-standing and integral part of the caregiver-patient relationship. Beginning in 1847, certain disease diagnoses have been mandated to be reported to the state and tracked as a public safety concern, although which diseases are tracked vary by state.1 The list of federally mandated reportable diseases includes AIDS, Lyme disease, meningococcal disease, tuberculosis, and others.2 Still other data are collected anonymously through large population surveys, of which there are many. And while broad reaching in their topics and unidentifiable to the individual, they are sample based and have seen a decline in response in recent years as people have switched to cell phone use and are more inundated with information requests.3 Thus, they pres-ent a less than accurate picture of health for some seg-ments of the population.Our health system is also a predominantly private and fragmented one. It serves many patients, provid-ers, manufacturers, drug companies, and insurers, and personal health information is shared between each. And while much of this information was necessary to carry out the care of the individual (and its payment), many question how that information is accessed and used. Examples of instances for disclosure could include marketing drugs to patients and providers, or disclosure by therapists when potential violence to a third party could occur.4In 1996 Congress passed the Health Insurance Portability and Accountability Act or HIPAA.  The law addressed privacy by attempting to extend the provider-patient privacy context to a changing health system.  HIPAA does not attempt to put parameters on who may share health information beyond that individu-als be involved in the direct care of the patient. The law states that the amount of information shared with those not involved in the care of the patient must be only the minimally necessary amount to accomplish the need at hand. This is an obviously vague and sub-jective provision and does not extend to those directly involved in patient care. Much of what HIPAA attempts to do is differentiate between what is meant by the security of health information and health information privacy. The idea of security is largely an information technology issue, and it is concerned with patient and provider identifiers, firewalls, encryption, and the like.  The University Dialogues  2010–2011 It is important, but its implementation necessitates that some definition of privacy and the parameters of privacy first be defined. The concept of privacy within medical doctrine has primarily concerned itself with the idea that patients’ must authorize access to and use of their medical information and also be able to review, correct, and obtain that information.5 And while HIPAA is an important standard for privacy and information sharing, it is only the minimum federal standard. Many state laws extend beyond HIPAA for certain individuals and in certain states. For example, in New Hampshire, a person’s medical information (not the paper it is printed on or database it rests within) is considered their private personal property, not the pro-vider’s, as is the case in many states.5 Many other states have special laws regarding privacy for individuals with HIV or with intellectual disability. But for the majority of individuals, the difficult task related to privacy is to define what is being granted control over; i.e., what con-stitutes personal health information? And what infor-mation is deemed “necessary” for treating the patient.  To consider these questions it is important to first define what in fact the goal of the health system is, and what is “health.”Understanding our HealthThe idea of “health” and what promotes health has been an issue of long-standing research and debate. In 1990, Robert Evans and Greg Stoddart put forward a now widely cited model of health that sug-gests that health is built upon a collective foundation of individual values and beliefs, which is modified by our gained experiences and our evaluation of those experiences.6 Having evidence-based research from medicine and public health is therefore paramount to being able to define our health. The model posits that there are a number of determinants to health, including our socio-economic status, our genetic make-up, our environment, and our access to health care services. In the United States, most of the nearly 2.3 trillion dol-lars spent on health is funneled through the medical care system, yet research has shown that access to care accounts for less than 10 percent of the variation in our collective health status.7 In fact, growing evidence suggests that socioeconomic factors may have the most impact in efforts to improve health outcomes.8-12This evidence is increasingly important in the United States, which ranked 37th of world countries in health outcomes by the World Health Organization in 2000 and last among six wealthy nations on dimensions of access, equity, efficiency, and overall health in 2007.13 In addition, U.S. health costs continue to rise at an unsustainable rate. Some projections show that by 2019, health spending will rise to near 4 trillion dollars a year or over 20 percent of our national Gross Domestic Product.14 This would mean one in every five dollars earned by a U.S. citizen would go to health care on average. In addition, we are now realizing epidemics of chronic diseases such as obesity, diabetes, asthma, heart disease, kidney disease, lung disease, dementia disor-ders, and others that are crippling our country both physically, and in terms of future cost burden.The evidence suggests societal changes could pro-mote a decrease in these trends, yet that evidence is incomplete. While the argument can be made on a population level that how you live, where you live, how much you earn, your level of education, and the comfort, safety, and amenities of your neighborhood matter to your health, it is unknown which of these contributes to health, how, and to what degree. This is partially because they are all intrinsically linked, and partially because there is no one source of data that pulls together an identifiable individual, their sociode-mographic and socioeconomic information, and links it with their health information and experience. The research questions are clear; however, the type of infor-mation we collect and how we collect it simply does not allow us to answer them. A Need for More Information?From a population health perspective, the need for better information is apparent. The need to slow health spending and improve quality has led many in government and the private sector to promote the use of electronic and linked health information as a potential first step in this solution. In 2004, the govern-ment formed the Office of the Controller for Health Information Technology, whose job it was to promote policies around data sharing, a concept known as interoperability, to this end. They list the following as rationale. Enhanced medical information interoperabil-ity will serve to:* Complete, accurate, and searchable health infor-mation, available at the point of diagnosis and care, allowing for more informed decision making to enhance the quality and reliability of health care delivery.* More efficient and convenient delivery of care, without having to wait for the exchange of records or paperwork and without requiring unnecessary or repetitive tests or procedures.TMI: Decision Making in the Age of Information Overload* Earlier diagnosis and characterization of disease, with the potential to thereby improve outcomes and reduce costs.* Reductions in adverse events through an improved understanding of each patient’s particular medi-cal history, potential for drug-drug interactions, or (eventually) enhanced understanding of a patient’s metabolism or even genetic profile and likelihood of a positive or potentially harmful response to a course of treatment.* Increased efficiencies related to administrative tasks, allowing for more interaction with and trans-fer of information to patients, caregivers, and clini-cal care coordinators, and monitoring of patient care. (http://healthit.hhs.gov/portal/server.pt)In 2010, President Obama signed the Patient Protection and Affordable Care Act, or what has come to be known as health care reform. In it are many provi-sions that are contingent upon a broader proliferation of information technology and data sharing in the health sector. Some relate to paying for quality of care, some around what prices are actually charged and paid, and some are related to tracking disease and its correlates. All of them require the collection and sharing of per-sonal health information between providers of care, those paying for care, researchers, and others in ways we currently do not. Yet many would say we currently collect too much information and are resistant to shar-ing that information from fear of discrimination due to health status or genetic disposition. Personal Privacy and the Public GoodA perceived right to privacy is core to American val-ues. In health care, it is rooted in the Hippocratic Oath and tradition which supports the privacy of the patient-provider relationship.4 But as discussed, the need to disclose personal information has been justified to protect third parties and for the public good in some cases. The idea of privacy has since evolved primarily around the principal of informed consent. Anyone who visits a provider’s office for the first time has no doubt signed an informed consent form, or more recently per-haps a privacy notice document, which typically stipu-lates that the patient has control over his or her health information and that the provider will not divulge that information except for certain purposes (dealing with health insurers for payment being one). Modern health care and its complexities now challenge the notion of a one provider-one patient record holder given that our health information is stored, recorded, and shared between so many entities. Infants are screened at birth and often before birth on a growing number of genetic conditions, many which get recorded with a state entity.  Blood samples rest with genetic registries. Pharmacies hold prescription records, labs store and transmit test values to specialists who may fax them to primary care doctors, and the list goes on. These data are used first for care purposes, but also secondarily in determin-ing the supply of services (vaccines, new technologies, growing trends), for payment, and for research.  The question then, is to what did the patient give consent for? Does the consent for care at the time of care also carry forward to secondary uses? Erring on the side of caution, however, is not without implication. For ex-ample, is it feasible that researchers investigating genetic medical innovations re-contact all of the children who were sampled at birth for their consent, and does this impose undue cost to new learning? Further, if the type of information collected becomes broader to include so-cioeconomic and sociodemographic information as so many claim is necessary to answer our pressing health questions, then how does informed consent fit, and is patient privacy truly an achievable idea?  Concluding StatementWe are living in a world witnessing exponential growth in technology and information. Data is being collected in more places, across more people, and about more things than at any time in our history.  Yet from a health perspective, we still know very little.  Doctors know a little about the health of their patients.  Insurers know a little about the health of their enroll-ees. And overall we know very little about the health of our population or the care being delivered. Yet in the U.S. we spend more on that care than any country in the world, get less for it, and risk crippling our ability to function economically by doing so. Future policy ef-forts need evidence-driven information to reverse these trends. So, in a world of too much information, is it possible that too much is still not enough? And are we willing to forgo some level of personal privacy for better health and to enhance the public good, or is there a way to accomplish both yet undetermined? The University Dialogues  2010–2011 References1. Bayer, R., Fairchild, A. The Limits of Privacy: Surveillance and the Control of Disease. Health Care Analysis. 2002; 10:19-35. 2. Centers for Disease Control. Update to Summary of Notifiable Diseases—United States. MMWR. 2008; 55(53):1-94. 3. Fowler F. How to Conduct General Population Surveys in the 21st Century. Eighth Conference on Health Survey Research Methods. 2007. 4. Gostin L. Healthcare information and the protection of personal privacy: ethical and legal considerations. Ann Intern Med. 1997; 127(8):683-690. 5. General Court NH. Medical Records Occupations and Professions, Patient information. 1989; RSA 332(a):1-2. 6. Evans RG, Stoddart GL. Consuming Research, Producing Policy? Am J Public Health. 2003; 93(3):371-379.7. Schroeder SA. We Can Do Better—Improving the Health of the American People. N Engl J Med. 2007; 357(12):1221-1228. 8. M M, Smith GD, SA S, Patel C, North F, Head J. Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991 (337):1387. 9. Macinko JA, Shi L, Starfield B, Wulu JT, Jr. Income in-equality and health: a critical review of the literature. Med Care Res Rev. 2003; 60(1077-5587; 4):407-452. 10. Macinko JA, Shi L, Starfield B. Wage inequality, the health system, and infant mortality in wealthy industrial-ized countries, 1970-1996. Soc Sci Med. 2004; 58(0277-9536; 2):279-292. 11. Robert S. Socioeconomic Position and Health: The Independent Contribution of Community Socioeconomic Context. Annual Rev Sociology. 2007; 25:489-516. 12. Robert SA. Socioeconomic Position and Health: The Independent Contribution of Community Socioeconomic Context. Annual Review of Sociology. 1999; 25:489-516. 13. Davis, K. Schoen, C. Schoenbaum, S. Doty, M. Holmgren, A. Kriss, J. Shea, K. Mirror on the Wall: An International Update on the Comparative Performance of American Health Care. The Commonwealth Fund. 2007. 14. Gruber J. The Cost Implications of Health Care Reform. N Engl J Med. 2010; 362(22):2050-2051. 

When is a lot still not enough? health information, the public good and privacy rights

University of New Hampshire

University of New Hampshire
University of New Hampshire Scholars' Repository
The University Dialogue Discovery Program
2010
When is a lot still not enough? health information,
the public good and privacy rights
Robert J. McGrath
University of New Hampshire, robert.mcgrath@unh.edu
Follow this and additional works at: https://scholars.unh.edu/discovery_ud
Part of the Health Communication Commons, and the Health Policy Commons
This Article is brought to you for free and open access by the Discovery Program at University of New Hampshire Scholars' Repository. It has been
accepted for inclusion in The University Dialogue by an authorized administrator of University of New Hampshire Scholars' Repository. For more
information, please contact nicole.hentz@unh.edu.
Recommended Citation
McGrath, Robert J., "When is a lot still not enough? health information, the public good and privacy rights" (2010). The University
Dialogue. 61.
https://scholars.unh.edu/discovery_ud/61
When is a lot still not enough?
Health information, the public good and privacy rights
Robert McGrath, Ph.D.
Assistant Professor of Health Management and Policy
The United States health care system is the largest in the world.  With annual spend-ing approaching 2.3 trillion dollars in 2009, it 
eclipses the entire gross domestic product of many other 
countries. Yet unlike many other industrialized nations, 
it is a fragmented system that relies primarily on pri-
vate markets for its provision. This reliance has led to 
similarly fragmented information about the health of 
individuals that in turn limits in some cases even a cur-
sory understanding of the health of the population as a 
whole.  Many have argued that some form of collective 
health information about the population is imperative 
to the betterment of society, and have called for uniform 
data collection that links health, socio-economic indica-
tors, indicators of health risks and the like so that future 
interventions might be better targeted most effectively. 
Yet others believe that such mandatory data collection 
is a violation of personal privacy and the basic rights 
of American citizens. The question remains: what level 
of information gathering is the appropriate one, and 
is health information collection possible that serves 
the public interest while still respecting the privacy of 
patients and citizens?
Health Information and Privacy:  A Brief 
History
Since the early days of organized medicine, physicians and other providers have collected, stored, and uti-
lized health and personal information to better care for 
patients. The recording of health histories, presenting 
symptoms, and other clinically related information has 
been a long-standing and integral part of the caregiver-
patient relationship. Beginning in 1847, certain disease 
diagnoses have been mandated to be reported to the 
state and tracked as a public safety concern, although 
which diseases are tracked vary by state.1 The list of 
federally mandated reportable diseases includes AIDS, 
Lyme disease, meningococcal disease, tuberculosis, 
and others.2 Still other data are collected anonymously 
through large population surveys, of which there are 
many. And while broad reaching in their topics and 
unidentifiable to the individual, they are sample based 
and have seen a decline in response in recent years as 
people have switched to cell phone use and are more 
inundated with information requests.3 Thus, they pres-
ent a less than accurate picture of health for some seg-
ments of the population.
Our health system is also a predominantly private 
and fragmented one. It serves many patients, provid-
ers, manufacturers, drug companies, and insurers, and 
personal health information is shared between each. 
And while much of this information was necessary to 
carry out the care of the individual (and its payment), 
many question how that information is accessed and 
used. Examples of instances for disclosure could include 
marketing drugs to patients and providers, or disclosure 
by therapists when potential violence to a third party 
could occur.4
In 1996 Congress passed the Health Insurance 
Portability and Accountability Act or HIPAA.  The law 
addressed privacy by attempting to extend the provider-
patient privacy context to a changing health system.  
HIPAA does not attempt to put parameters on who 
may share health information beyond that individu-
als be involved in the direct care of the patient. The 
law states that the amount of information shared with 
those not involved in the care of the patient must be 
only the minimally necessary amount to accomplish 
the need at hand. This is an obviously vague and sub-
jective provision and does not extend to those directly 
involved in patient care. Much of what HIPAA attempts 
to do is differentiate between what is meant by the 
security of health information and health information 
privacy. The idea of security is largely an information 
technology issue, and it is concerned with patient and 
provider identifiers, firewalls, encryption, and the like.  
The University Dialogues  2010–2011 
It is important, but its implementation necessitates 
that some definition of privacy and the parameters of 
privacy first be defined. The concept of privacy within 
medical doctrine has primarily concerned itself with 
the idea that patients’ must authorize access to and 
use of their medical information and also be able to 
review, correct, and obtain that information.5 And 
while HIPAA is an important standard for privacy and 
information sharing, it is only the minimum federal 
standard. Many state laws extend beyond HIPAA for 
certain individuals and in certain states. For example, 
in New Hampshire, a person’s medical information (not 
the paper it is printed on or database it rests within) is 
considered their private personal property, not the pro-
vider’s, as is the case in many states.5 Many other states 
have special laws regarding privacy for individuals with 
HIV or with intellectual disability. But for the majority 
of individuals, the difficult task related to privacy is to 
define what is being granted control over; i.e., what con-
stitutes personal health information? And what infor-
mation is deemed “necessary” for treating the patient.  
To consider these questions it is important to first define 
what in fact the goal of the health system is, and what is 
“health.”
Understanding our Health
The idea of “health” and what promotes health has been an issue of long-standing research and 
debate. In 1990, Robert Evans and Greg Stoddart put 
forward a now widely cited model of health that sug-
gests that health is built upon a collective foundation 
of individual values and beliefs, which is modified by 
our gained experiences and our evaluation of those 
experiences.6 Having evidence-based research from 
medicine and public health is therefore paramount to 
being able to define our health. The model posits that 
there are a number of determinants to health, including 
our socio-economic status, our genetic make-up, our 
environment, and our access to health care services. In 
the United States, most of the nearly 2.3 trillion dol-
lars spent on health is funneled through the medical 
care system, yet research has shown that access to care 
accounts for less than 10 percent of the variation in 
our collective health status.7 In fact, growing evidence 
suggests that socioeconomic factors may have the most 
impact in efforts to improve health outcomes.8-12
This evidence is increasingly important in the United 
States, which ranked 37th of world countries in health 
outcomes by the World Health Organization in 2000 
and last among six wealthy nations on dimensions of 
access, equity, efficiency, and overall health in 2007.13 
In addition, U.S. health costs continue to rise at an 
unsustainable rate. Some projections show that by 2019, 
health spending will rise to near 4 trillion dollars a 
year or over 20 percent of our national Gross Domestic 
Product.14 This would mean one in every five dollars 
earned by a U.S. citizen would go to health care on 
average. In addition, we are now realizing epidemics of 
chronic diseases such as obesity, diabetes, asthma, heart 
disease, kidney disease, lung disease, dementia disor-
ders, and others that are crippling our country both 
physically, and in terms of future cost burden.
The evidence suggests societal changes could pro-
mote a decrease in these trends, yet that evidence is 
incomplete. While the argument can be made on a 
population level that how you live, where you live, 
how much you earn, your level of education, and the 
comfort, safety, and amenities of your neighborhood 
matter to your health, it is unknown which of these 
contributes to health, how, and to what degree. This is 
partially because they are all intrinsically linked, and 
partially because there is no one source of data that 
pulls together an identifiable individual, their sociode-
mographic and socioeconomic information, and links 
it with their health information and experience. The 
research questions are clear; however, the type of infor-
mation we collect and how we collect it simply does not 
allow us to answer them. 
A Need for More Information?
From a population health perspective, the need for better information is apparent. The need to slow 
health spending and improve quality has led many 
in government and the private sector to promote the 
use of electronic and linked health information as a 
potential first step in this solution. In 2004, the govern-
ment formed the Office of the Controller for Health 
Information Technology, whose job it was to promote 
policies around data sharing, a concept known as 
interoperability, to this end. They list the following as 
rationale. Enhanced medical information interoperabil-
ity will serve to:
* Complete, accurate, and searchable health infor-
mation, available at the point of diagnosis and care, 
allowing for more informed decision making to 
enhance the quality and reliability of health care 
delivery.
* More efficient and convenient delivery of care, 
without having to wait for the exchange of records 
or paperwork and without requiring unnecessary 
or repetitive tests or procedures.
TMI: Decision Making in the Age of Information Overload
* Earlier diagnosis and characterization of disease, 
with the potential to thereby improve outcomes 
and reduce costs.
* Reductions in adverse events through an improved 
understanding of each patient’s particular medi-
cal history, potential for drug-drug interactions, or 
(eventually) enhanced understanding of a patient’s 
metabolism or even genetic profile and likelihood 
of a positive or potentially harmful response to a 
course of treatment.
* Increased efficiencies related to administrative 
tasks, allowing for more interaction with and trans-
fer of information to patients, caregivers, and clini-
cal care coordinators, and monitoring of patient 
care. (http://healthit.hhs.gov/portal/server.pt)
In 2010, President Obama signed the Patient 
Protection and Affordable Care Act, or what has come 
to be known as health care reform. In it are many provi-
sions that are contingent upon a broader proliferation of 
information technology and data sharing in the health 
sector. Some relate to paying for quality of care, some 
around what prices are actually charged and paid, and 
some are related to tracking disease and its correlates. 
All of them require the collection and sharing of per-
sonal health information between providers of care, 
those paying for care, researchers, and others in ways 
we currently do not. Yet many would say we currently 
collect too much information and are resistant to shar-
ing that information from fear of discrimination due to 
health status or genetic disposition. 
Personal Privacy and the Public Good
A perceived right to privacy is core to American val-ues. In health care, it is rooted in the Hippocratic 
Oath and tradition which supports the privacy of the 
patient-provider relationship.4 But as discussed, the 
need to disclose personal information has been justified 
to protect third parties and for the public good in some 
cases. The idea of privacy has since evolved primarily 
around the principal of informed consent. Anyone who 
visits a provider’s office for the first time has no doubt 
signed an informed consent form, or more recently per-
haps a privacy notice document, which typically stipu-
lates that the patient has control over his or her health 
information and that the provider will not divulge that 
information except for certain purposes (dealing with 
health insurers for payment being one). Modern health 
care and its complexities now challenge the notion of 
a one provider-one patient record holder given that 
our health information is stored, recorded, and shared 
between so many entities. Infants are screened at birth 
and often before birth on a growing number of genetic 
conditions, many which get recorded with a state entity.  
Blood samples rest with genetic registries. Pharmacies 
hold prescription records, labs store and transmit test 
values to specialists who may fax them to primary care 
doctors, and the list goes on. These data are used first 
for care purposes, but also secondarily in determin-
ing the supply of services (vaccines, new technologies, 
growing trends), for payment, and for research.  The 
question then, is to what did the patient give consent 
for? Does the consent for care at the time of care also 
carry forward to secondary uses? Erring on the side of 
caution, however, is not without implication. For ex-
ample, is it feasible that researchers investigating genetic 
medical innovations re-contact all of the children who 
were sampled at birth for their consent, and does this 
impose undue cost to new learning? Further, if the type 
of information collected becomes broader to include so-
cioeconomic and sociodemographic information as so 
many claim is necessary to answer our pressing health 
questions, then how does informed consent fit, and is 
patient privacy truly an achievable idea?  
Concluding Statement
We are living in a world witnessing exponential growth in technology and information. Data 
is being collected in more places, across more people, 
and about more things than at any time in our history.  
Yet from a health perspective, we still know very little.  
Doctors know a little about the health of their patients.  
Insurers know a little about the health of their enroll-
ees. And overall we know very little about the health of 
our population or the care being delivered. Yet in the 
U.S. we spend more on that care than any country in 
the world, get less for it, and risk crippling our ability 
to function economically by doing so. Future policy ef-
forts need evidence-driven information to reverse these 
trends. So, in a world of too much information, is it 
possible that too much is still not enough? And are we 
willing to forgo some level of personal privacy for better 
health and to enhance the public good, or is there a way 
to accomplish both yet undetermined? 
The University Dialogues  2010–2011 
References
1. Bayer, R., Fairchild, A. The Limits of Privacy: Surveillance 
and the Control of Disease. Health Care Analysis. 2002; 
10:19-35. 
2. Centers for Disease Control. Update to Summary of 
Notifiable Diseases—United States. MMWR. 2008; 55(53):1-94. 
3. Fowler F. How to Conduct General Population Surveys 
in the 21st Century. Eighth Conference on Health Survey 
Research Methods. 2007. 
4. Gostin L. Healthcare information and the protection of 
personal privacy: ethical and legal considerations. Ann Intern 
Med. 1997; 127(8):683-690. 
5. General Court NH. Medical Records Occupations and 
Professions, Patient information. 1989; RSA 332(a):1-2. 
6. Evans RG, Stoddart GL. Consuming Research, Producing 
Policy? Am J Public Health. 2003; 93(3):371-379.
7. Schroeder SA. We Can Do Better—Improving the Health 
of the American People. N Engl J Med. 2007; 357(12):1221-
1228. 
8. M M, Smith GD, SA S, Patel C, North F, Head J. Health 
inequalities among British civil servants: the Whitehall II 
study. Lancet. 1991 (337):1387. 
9. Macinko JA, Shi L, Starfield B, Wulu JT, Jr. Income in-
equality and health: a critical review of the literature. Med 
Care Res Rev. 2003; 60(1077-5587; 4):407-452. 
10. Macinko JA, Shi L, Starfield B. Wage inequality, the 
health system, and infant mortality in wealthy industrial-
ized countries, 1970-1996. Soc Sci Med. 2004; 58(0277-9536; 
2):279-292. 
11. Robert S. Socioeconomic Position and Health: The 
Independent Contribution of Community Socioeconomic 
Context. Annual Rev Sociology. 2007; 25:489-516. 
12. Robert SA. Socioeconomic Position and Health: The 
Independent Contribution of Community Socioeconomic 
Context. Annual Review of Sociology. 1999; 25:489-516. 
13. Davis, K. Schoen, C. Schoenbaum, S. Doty, M. Holmgren, 
A. Kriss, J. Shea, K. Mirror on the Wall: An International 
Update on the Comparative Performance of American 
Health Care. The Commonwealth Fund. 2007. 
14. Gruber J. The Cost Implications of Health Care Reform. 
N Engl J Med. 2010; 362(22):2050-2051. 


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When is a lot still not enough? health information, the public good and privacy rights

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