James Fallows is a national correspondent for The Atlantic and has written for the magazine since the late 1970s. He has reported extensively from outside the United States and once worked as President Carter's chief speechwriter. His latest book is China Airborne.
James Fallows is based in Washington as a national correspondent for The Atlantic. He has worked for the magazine for nearly 30 years and in that time has also lived in Seattle, Berkeley, Austin, Tokyo, Kuala Lumpur, Shanghai, and Beijing. He was raised in Redlands, California, received his undergraduate degree in American history and literature from Harvard, and received a graduate degree in economics from Oxford as a Rhodes scholar. In addition to working for The Atlantic, he has spent two years as chief White House speechwriter for Jimmy Carter, two years as the editor of US News & World Report, and six months as a program designer at Microsoft. He is an instrument-rated private pilot. He is also now the chair in U.S. media at the U.S. Studies Centre at the University of Sydney, in Australia.
Fallows has been a finalist for the National Magazine Award five times and has won once; he has also won the American Book Award for nonfiction and a N.Y. Emmy award for the documentary series Doing Business in China. He was the founding chairman of the New America Foundation. His recent books Blind Into Baghdad (2006) and Postcards From Tomorrow Square (2009) are based on his writings for The Atlantic. His latest book is China Airborne. He is married to Deborah Fallows, author of the recent book Dreaming in Chinese. They have two married sons.
Fallows welcomes and frequently quotes from reader mail sent via the "Email" button below. Unless you specify otherwise, we consider any incoming mail available for possible quotation -- but not with the sender's real name unless you explicitly state that it may be used. If you are wondering why Fallows does not use a "Comments" field below his posts, please see previous explanations here and here.
Toccoa airport, Georgia, on the way in. (Deborah Fallows)
It has been a full and interesting day in the air, from Maryland to Mississippi, and a longer day than expected for a surprisingly touching reason.
Reinvention and resilience across the nation Read more
By chance, en route from KGAI, Montgomery Country Airpark outside Washington, to KUBS, the Lowndes County airport in Columbus, Mississippi, we ended up stopping for gas and a break in a place we hadn't expected. It wasn't the site I'd had in mind in Tennessee (because that would have meant going over the mountains near Asheville while the winds turned out to be stronger than I would have liked for crossing mountains). Nor the one I was thinking of in South Carolina (because the post-storm winds in the area were gustier, and not aligned with the runway, than would be convenient). Nor some other place in Alabama -- but, at the last minute, KTOC, the Toccoa / Stephens County Airport in northern Georgia. At the top of the item you see the way its main runway looked as we decided to head in there.
After we landed, I taxied over to the fuel pump and gassed up the airplane, while Deb went into the FBO office to say hello. A minute later she came back out. "Timing is everything," she said, for the millionth time over the years. On entering what is usually a spartan, utilitarian area for checking weather, filing flight plans, and buy snacks out of vending machines, she was immediately charmed by the aroma of roasted ham, candied yams, creamed green beans and broccoli, and other delicacies that recalled her Midwestern childhood. (Below, a counter in one of the pilot rooms at the Toccoa FBO. You would usually expect to see surfaces covered with flight charts, headsets, and so on.)
It was an extended-family potluck Easter banquet right at the FBO, and the families putting it on said: Please join us! And so we (gratefully) did, as part of a multi-generational, multi-family celebration at a little airfield in the middle of the Georgia hills. This was all the more appealing because our presumed alternative had been beef jerky inside the plane.
These people had never seen us before but made us part of the extended family celebration for the afternoon. We heard about why people liked (or didn't) Toccoa, why some people moved away, why others wanted to move there -- and why its famous falls have a vertical drop higher even than Niagara's. Here is where we sat while enjoying ham and everything else.
"We feel very lucky to have ended up here just now," I told the airport manager as we were heading out, toward Mississippi. "Or you could say you were blessed," he said. "You'll remember us, either way!"
In the current issue, I have a brief story based on an interview with Steven Chu and Yi Cui, now both of Stanford, about advances in the seemingly boring but actually exciting world of battery technology, and why that is essential to lower-carbon, cleaner-fuel power systems.
The discouraging signals in the race for less destructive paths toward growth keep piling up. For instance, the recent charts about air pollution in China*. Yet like every systemic problem human beings have created for themselves and then tried to correct, this is an all-out race, between destruction and creation. On the positive side, we have this brief new report from McKinsey, which is source of the chart at top.
The report (by Sara Hastings-Simon, Dickon Pinner, and Martin Stuchtey) concerns the pace and feasibility of "cleantech" installations, and why they may be more feasible than they have seemed. The main problem with solar, wind, tidal, and other low-carbon energy sources has involved scale. Clean power sources have represented so tiny a share of the world's energy base, and coal's share has been so huge, that even as wind etc have expanded very fast in proportional terms, absolute demand for (and emissions from) coal keep going up fast. These scale realities are why, as I argued several years ago in an Atlantic cover story, developing cleaner coal is not a contradiction but a necessity. Charles Mann has a good new Wired story on the current complexion of the "cleaner coal" debate.
And now some more positive news from McKinsey, about a pending rapid increase in the feasibility of cleaner sources. The report begins:
The world is on the cusp of a resource revolution. As our colleagues Stefan Heck and Matt Rogers argue, advances in information technology, nanotechnology, materials science, and biology will radically increase the productivity of resources. The result will be a new industrial revolution that will enable strong economic growth, at a much lower environmental cost than in the past, thanks to the broad deployment of better, cleaner technologies and the development of more appropriate business models.
Then it raises the obvious objection:
But how do we reconcile this bold and heartening prediction with recent challenges experienced by cleantech, the general term for products and processes that improve environmental performance in the construction, transport, energy, water, and waste industries?
And goes on to suggest an answer. Worth checking out.
* Several people have written to ask about my assertion in the Chinese smog item: "No one now alive has experienced anything similar in North America or Europe, except in the middle of a forest fire or a volcanic eruption." The main counter-example offered is the Great London Smog of 1952, which blanketed the city for four days and may have contributed to thousands of premature deaths.
I'm not aware of any way to compare pollution readings from that era and this; most estimates are that Chinese air pollution now prematurely kills many hundreds of thousands people each year; and in any case we are comparing a four-day emergency in one very large city with ongoing, years-long reality in many places in the world's most populous country. Similarly, the four-day-long Donora smog emergency of 1948 is thought to have killed 20 people in Pennsylvania, or less than the average premature deaths in China because of air pollution per hour.
Still, in the interests of precision I am happy to amend the original claim as follows: "No one now alive has experienced anything similar in North America or Europe, except in the middle of a forest fire or a volcanic eruption, or in London over four days 62 years ago."
At least from our perspective, the discussion was a lot of fun, including in hinting at some of the changes wrought even in a long and happy marriage that has seen its share of other odd locales, once you start trekking around the country in a little plane.
Tonight the hour-long program is scheduled to be shown on C-SPAN at 8pm Eastern. If you're interested, please check it out there. C-SPAN schedules sometimes change at short notice, but that is the plan for now.
The C-SPAN broadcast probably does not include a sequence of en-route snapshots we've taken through the months on the road (and in the air). These were run as B-roll before the program began, and they're available in un-annotated form as a G+ album. And that map at top is explained in this previous post.
I was sorrier than I can say to have learned today that Michael Janeway, a friend who influenced many journalistic institutions but probably most of all The Atlantic, had died of cancer.
The Boston Globe, where Mike held a sequence of editing roles including that of editor in chief, ran a wonderful appreciation by Joseph Kahn, which is true to the range of achievements and complexities in his life and career. I mention it both in hopes that you'll read Kahn's article and as an excuse to offer a screen shot of the Globe photo by Stan Grossfeld that accompanied the obit, which is of Michael Janeway in his mid-40s and captures him at his sunniest.
Mike Janeway is known in journalism for a series of influential roles: at the Globe, where he fostered talent and invented or revitalized sections before a stormy period as head editor; then as a book editor at Houghton Mifflin; then as dean of the Medill School of Journalism at Northwestern, where he foresaw and discussed many of the trends all of journalism is now coping with; then as a professor at Columbia Journalism School; and as an author, including of a history-memoir of the New Deal-and-afterwards policy intelligentsia.
This last (The Fall of the House of Roosevelt) was cast as memoir because Mike's parents, the economist Eliot Janeway and the novelist Elizabeth Janeway, were in the middle of this group, and Mike grew up hearing stories about them and meeting luminaries around the house. It also turned on Mike's difficult relationship with his then-quite famous father, as you can see from the book itself or via Michael Beschloss's fine review in the NYTBR. Among the Janeways' New Deal contacts had been the rising Congressman Lyndon Johnson. As a teenager Mike had a summer job working on Capitol Hill for Senator Johnson, and he remained deeply interested in the grandeur and the tragedy of the ultimate Johnson saga: the ambitions for a Great Society and a "we shall overcome!" civil-rights movement, the disaster of Vietnam. The circle of people grappling with the contradictions of Johnson -- of whom Robert Caro is best known now but that also includes Billy Lee Brammer, Bill Moyers, Doris Kearns Goodwin, James C. Thomson, Harry McPherson -- very much included Mike Janeway.
That's the journalism world in general. His influence on the Atlantic specifically was profound. In 1967, five years out of college, he joined the magazine as a staff editor. Robert Manning had just become editor and was shifting the magazine toward coverage of the great upheavals of that time -- race relations, wealth and poverty, Vietnam, all the rest. On their watch the magazine published probably the best real-time assessment of what was going wrong in Vietnam, James C. Thomson's "How Could Vietnam Happen? An Autopsy" -- and a long sequence of other journalism that stands up nearly two generations later. In 1968, when Mike was 28, he and Manning co-edited an influential book of writing about Vietnam, called Who We Are. The magazine you see today is an extension of what Manning, Janeway, Richard Todd, Louise Desaulniers, Michael Curtis, and others (including Elizabeth Drew, the Washington correspondent) created in those years.
I was in college then, and I would rush out to the newsstand -- yes, that's how it worked in those days -- to get the new issues of The Atlantic, and Harper's, and the nascent Rolling Stone.I barely dared imagine then that I could eventually write for one of these publications, and that I managed to write for the Atlantic is due to Mike Janeway.
After I heard the news about Mike today, I stopped to reflect that a small group of people (outside my family) gave me crucial opportunities, support, and direction at important early moments in my path. One, perhaps improbably, was Ralph Nader, under whose auspices and at whose prodding I ended up writing two books very soon after leaving college. Another was, of course, Charles Peters, whose role in training generation after generation of reporters and writers at The Washington Monthly is well-known at least within the business.
Another was Michael Janeway. After I had finished my Washington Monthly stint and was trying to get a start as a free-lancer based in Texas,he entertained one proposal for an Atlantic story. After he nursed me through that one, there was another, and another. Years later, when he was at Houghton Mifflin and I had run into trouble with a different publisher with my idea for a book, he took it over and guided it to what I found a very satisfying conclusion. (This was More Like Us.) When he was dean at Medill-Northwestern, he invited me to give a speech that became the outline and impetus for my book Breaking the News. All of this doesn't matter to anyone else, but it mattered a lot to me, and his example (plus others') is in my mind as I think about dealing with people now trying to get a start.
As Joseph Kahn's excellent Globestory conveys, Michael Janeway was not always an easy-going man -- toward others, or on himself. I am glad for the reports that he became more contented in his latest years. I am sorry that I did not think to tell him directly how much he had meant to his profession, and to this magazine, and to me, but I wanted to say it to his family members now.
Everyone "knows" that China is badly polluted. I've written over the years, and still believe, that environmental sustainability in all forms is China's biggest emergency, in every sense: for its people, for its government, for its effect on the world. And yes, I understand that the same is true for modern industrialized life in general. But China is an extreme case, and an extremely important one because of its scale.
Here are two simple charts, neither of them brand-new but both easily comprehensible, that help dramatize how different the situation is there. The first, by Steven Andrews for China Dialoguevia ChinaFile, compares official Chinese classifications of "good" air conditions with those in Europe or North America.
Here is the point of this graphic: The green and yellow zones in the left-hand column, showing official Chinese government classifications, are for "good" or "OK" air—while those same readings would be in the danger zone by U.S. or European standards. When you're living in China, it's impossible not to adjust your standards either to ignore how dire the circumstances are, so you can get on with life, or to think that any day when you can see across the street is "pretty good."
The scale for all countries stops at 250 (micrograms per cubic meter). Everyone who has spent time in Beijing or other bad-air cities knows what it is like with readings of 500 or above. Even Shanghai had a 600+ "airpocalypse" this past winter. No one now alive has experienced anything comparable in North America or Europe, except in the middle of a forest fire or a volcanic eruption.
Here's the other chart, comparing the 10 most-polluted Chinese cities with the 10 in America. It is from The Washington Post a few weeks ago:
The U.S. readings on this chart show something about challenges in the Central Valley of California, which is where six of the seven most-polluted cities are. (And the other is Los Angeles.) More on that shortly, in our American Futures series. But the scale difference of Chinese pollution is sobering. Even the worst American cities would be in the tip-top most excellent bracket in the chart at the top.
More sobering still: Air pollution, while the most visible (literally), is not the most serious of China's environmental problems. Water pollution, and water shortage, are worse.
First, from someone in this business, a vivid and specific illustration of the overall distortion of the medical marketplace.
I'm an independent IT consultant, working mostly with solo practitioners and small (2-10 doctors) practices. My clients choose their practice management and EMR software (sometimes they ask me for advice, but usually the choice has already been made by the time I get involved) and I help them make it work.
Over the past few years, I've worked with about 15 different EMRs, and I've developed a theory: all EMRs suck; they just suck in different ways.
However, despite my frustrations, I'm convinced that this is a good and necessary thing to do, and will lead to advantages not only for wider patient care but for doctors themselves (though they'll kick and scream even while they benefit; it's just something they do.)
I thought I'd indulge myself (and bore you, no doubt) with a few observations:
- Software companies in "vertical" markets have never been magnets for top programming talent...
- Nowhere is the lack of star talent more glaringly obvious than in user-interface design. To be fair, there is an awful lot of information to be captured, and Medicare* frowns on too-great indulgence in boilerplating - but sometimes I am staggered by the sheer number of clicks required to get through even the simplest of screens, and there are far too many screens.
- Counterintuitively, some of the most physician-UNfriendly interfaces I've seen were designed by physicians. With very few exceptions, users are lousy at designing their own tools! One of the best I've seen is Practice Fusion, which is a relatively new company started by Silicon Valley/Web 2.0 types (breaking the old vertical-software paradigm.)
- The back-turned-to-the-patient issue is an easy one to solve: use a tablet, or a laptop on a rolling stand, and face the patient (or stand next to them.) The fact that such an easily-solved problem is so widely cited as a deal-breaker says more, I think, about the mindset of physicians than about the technology itself.
- Nuance Communications has a virtual lock on the voice-recognition market**, and they exploit it in ways that I frankly find appalling. Dragon Dictate Home Edition is about $50; Premium is around $100-150; Professional around $500... but Dragon Medical is $1500. The only real difference between Premium and Medical is a pre-trained vocabulary; I can see charging extra for that if the user wants it - but all non-Medical editions of Dragon check for EMR software and will not run if it's present. If you're a doctor, no edition of Dragon but Medical will run on your machine. Furthermore, updates for other editions are available on Nuance's website so that if you upgrade, e.g. from Windows XP to 7, you don't have to buy a new copy of Dragon - but Medical users are left twisting in the wind. [JF note: I agree. I like and use Dragon/Nuance software but have been astonished by the tiered pricing. For the record, I've bought and personally paid for the Professional version.]
- Data interchange between competing EMRs is laughable. There are national and international standards for this (HL7, CCR/CCD, etc.), but no EMR company takes this seriously - they generally do an OK job of exporting data but are completely clueless about importing it. (If CERN, ARPA, and the big universities had acted like these guys, there'd be no Internet.) The biggest player in "gluing" various systems/equipment/etc. together is an open-source software project called Mirth, and the company/foundation that looks after it (think Mozilla, basically.) Earlier this year, Mirth was purchased by NextGen, one of the largest EMR companies. I'm keeping my fingers crossed that NextGen will adopt Mirth's mission of connecting the medical world... but I fear that Mirth will simply wither and die.
* Medicare _and all the other insurers_, but Medicare's the one with real teeth so I use them as shorthand.
** There used to be several other players in the voice-recognition market - SpeechWorks, ViaVoice, Jott, Loquendo, Transcend, etc. - but Scansoft (now Nuance) bought them all and either killed them off or folded them into Dragon. Google's speech recognition engine is the only real competition left (Siri, of course, is powered by Dragon), and Google doesn't provide a product that works with EMRs.
Now, about the public-health advantages that may offset some of the individual-practitioner annoyances:
I've been following all the different pieces around the EMR/EHR work--and it feels like a lot of the folks who've been writing in are really missing the forest for the trees--everyone's really missing is how important these innovations are to population health. Even working in a medically underserved community, this has changed how I work with leaps and bounds over the past five years.
Want to know how many smokers there are in a specific zip code who are served by your clinic or hospital? Want to be alerted whenever one of your patients go into the ED? Want to see a panel of what percentage of patients have diet-related co-morbidities? Want to know who a patient's Primary Care Provider? Want to geographically hot-spot specific health problems? All these things are infinitely easier with the existences of both EMRs/EHRs.
In other words, we can know so much more in so much less time. Rather than sending some poor soul into stacks upon stacks of ill-organized and non-standard hard copy medical records to sort through items, you can simply find it through a relatively (though not completely) understandable electronic system.
An example from my work is telling...we work with a variety of hospitals and clinics on a large public health project, which requires them to pull data, quarterly, on how many diabetic patients they have and how many of those diabetic patients smoke. For those few facilities still using hard copy records, we can only ask them to pull a sample of their data--and it takes two full days for their entire team to pull that information. At our EMR/EHR facilities, one person can pull all of the necessary information in a fraction of that time.
Yes, its almost certainly more cumbersome for practitioners --but it makes a drastic improvement in the quality of care coordination and the quality of data collected.
Our new issue is out. I know that you've already Subscribed! Meanwhile, apart from all the other value between its covers -- and really, a lot of exceptional pieces in this issue -- these housekeeping points involving me:
I have a one-page precis of some exciting developments in the non-exciting-seeming realm of battery technology. This is based on an interview with Steven Chu -- former Secretary of Energy, winner of the Nobel prize in physics, now professor at Stanford -- and Yi Cui, another Stanford professor who is at the frontier of battery research. Batteries don't get the big headlines, but as these professors explain, they're the key to most hopes for shifting to cleaner energy sources.
That precis came from a much longer interview. We'll have an extended-play version of that interview available online soon. Stay tuned.
By the luck of the draw, the past two issues of the magazine have included articles by me each of which had an unfortunate typo. In this battery story, it was "electrode" in a sentence that should have said "electron." We've fixed the online version. In the previous month's story, a sentence that should have said that Burlington, Vermont's minor league baseball team "was" the Reds -- as they were, when then-mayor Bernie Sanders brought them to town -- instead said that the team "is" the Reds. As anyone who has been to Vermont knows, the current team is of course the Vermont Lake Monsters.
We try harder, and do better, than most publications in avoiding mistakes of all sorts, including typos. But I am chagrined that in the millions of words we/I put out, these consequential letters were wrong: de rather than ns in one article, and i rather than wa in another.
Steven Chu, a Nobel laureate and former secretary of energy, and Yi Cui, a celebrated battery researcher who works with Chu at Stanford, describe how an overhaul of the unglamorous battery will jump-start a shift to renewable energy.
This evening James Bennet, the Atlantic's editor-in-chief, will be leading a conversation with Deb Fallows and me about the American Futures travels we've undertaken for the past few months, and for which we're about to kick off another extended trek.
Reinvention and resilience across the nation Read more
It will be at the historic Sixth and I Street Synagogue in Washington, whose address I will let you figure out for yourself, starting at 7pm. If you're in the vicinity, please come by.
Our partners in this project have been Marketplace, with whom we've done a series of joint broadcasts and web features, and the mapping company Esri, of Redlands, California. What you see below is the counterpart of a first-grader's finger-painted version of an Esri map. This is one I've thrown together to give a rough-and-ready idea of where we've gone, and where we're likely to head next.
It's zoomable and so on, but the main idea is: Red stars show places where we've made extended visits, green ones are shorter couple-day stops -- in both cases, including areas we'll start describing soon. (Including Greer, South Carolina, and Fresno and Winters in California.) The blue stars are places we're looking at starting a few days from now. And the parti-colored lines are a random assortment of routes we actually flew in the airplane, or places we went on our California swing, by car. (The dotted lines are by car.)
Here is a more sophisticated-looking map, by John Tierney and Svati Narula, showing the cities about which people have written in to suggest a visit. The biggest the green dot, the more proposals we've received.
In principle we'd love to see all of them. For a look at what we've learned so far, hope to see you this evening. Then we're off for some of the sites in blue below:
"Just as cars are not all the same, Electronic Medical Records vary greatly. A Mercedes, a Maserati and a Yugo are all cars, but you certainly wouldn't accuse someone of rejecting a used Yugo as being a Luddite and hating all cars. Similarly, you shouldn't generalize physicians who reject terrible programs as hating EMR."
Background: In last month's issue (subscribe!) I had a brief Q&A with Dr. David Blumenthal, who had kicked off the Obama Administration's effort to encourage use of electronic medical records. Since then, the mail has kept gushing in, as reported in previous as reported in in our April issue, about why the shift has been so difficult and taken so long. Previous multi-message compendia are available in installments one, two, three, four, five, and six.
As an operational matter, I am going to start doling these out one or sometimes two at a time, on a every-day-or-two basis. They'll have headlines based on this one's, and I will try to figure out some standardized image or illustration as cues that these are part of a series. Generally I'll post these without comment; they're meant to be part of a cumulative conversation among medical professionals, technologists, and the rest of us who are merely patients and bill-payers.
Let's start with two—one from a patient, one from a doctor.
Patient (and tech veteran): I can't stand filling out these damned forms over and over again.
I've been in the high tech industry since I graduate college in 1986, watching it grow from a specialized industry to the giant, interpenetrated octopus it is now. My wife also is in high tech, and indeed started out ... installing EMR systems in hospitals in the early 90s. Just a couple of quick thoughts:
First, if someone—ANYONE—can come up with a system that would prevent me from having to fill out THE SAME information over and over again just because I'm seeing a different doctor, I WILL TAKE IT. You get the same information requirements, but they're all on different forms, in different formats, from different doctors. But all the base information is exactly the same: Name, address, social security number, marital status, kids, insurance info, and so on. It's all the same. I'm seeing a doctor who was recommended by my GP; why in god's name am I filling out yet another form by hand. In 2014. When what most offices do is take my information and ... enter it into their databases by hand. How inefficient can you get? Hell, some doctors require you to put the exact same info *on multiple forms*. There has got to be a better way. [JF note: This is also my experience-as-patient, and I share the exasperation.]
I've long thought what we need is a card that is programmable, the size of a credit or insurance card, that you swipe through a reader, punch in a security code, and it downloads the info to the new doctor's system. Why no one has implemented this I have no idea.
Another note: I'm sure that a lot of the difficulty is incompatible systems, systems that don't play nice with various insurance companies, systems that don't interact with each well, and so on. This is not an inherent flaw of the technology—it would be no different if they were doing everything on paper, and then found, shit, we're using legal-sized, but the insurance requires 8.5 x 11! Or some other mundane problem with paper records. I don't know of any way around the problem other than mandated standards—"Everyone will use Oracle," or some such—and that's not going to happen. But the answer isn't to go backwards, or we'll end up with ink pots and quills.
Finally, I have to believe that the second doctor whom you quote is forced to use three systems partly by insurance-company requirements. I have to believe that if we had single-payer, that would simplify the record-keeping and IT problem considerably.
Doctor: A female doctor—as she notes, her gender is relevant to one of her points—says it's important to distinguish between good and bad systems.
I am a 50+ yo hospitalist (yes, the dreaded hospitalist bogeyman) and have been one for 17+ years. A couple of points, if I may:
1- there's a lot of talk about EMR as an entity without really addressing the quality of the EMR's. Just as cars are not all the same, EMR's vary greatly. A Mercedes, a Maserati and a Yugo are all cars, but you certainly wouldn't accuse someone of rejecting a used Yugo as being a Luddite and hating all cars. Similarly, you shouldn't generalize physicians who reject terrible programs as hating EMR.
They just enacted an EMR/CPOE [CPOE=Computerized Physician Order Entry] at my hospital. The reason this particular program was selected was money, savings by choosing a cheap program and avoiding the federal penalty. It is so difficult to use and (as many other commenters noted) fills your noted with drek and making the useful information difficult to find.
The program is so awful, in addition to parts of it being mouse driven, you need to use function keys and arrow keys to navigate. (Just hit F9, Dr. Smith...) When was the last time, in 2014, you were forced to learn a new program that required you to navigate that way? You can't search, you need to know the specific names for tests (CT chest rather than chest CT, dysphagia exam versus video swallow) and you need to click up to 30-40 times to get through something that previously required you to write 1 order. You can accidentally (and dangerously) erase the patient's entire plan of care with 2 clicks (one poor nurse spent 2 hours trying to recreate it) but you need click to confirm and verify multiple things that are clinically insignificant.
I would love an elegant program that enhanced patient care, was safe and made my job easier. Love, love, love it. But instead, I am painted (per lots of your communicants) as a intransigent luddite who doesn't want to move forward. Nothing could be further from the truth.
(By the way, that picture you posted on March 24, with Xrays accessed on the left, trending labs and graphs, looked great! All that info at your fingertips, integrated into the system. What program was that?) [JF note: it appears to have been an "artist's conception" image rather than a real program.]
2-I am an Apple fan. I don't care what the computer has regarding the hardware, I just want it to work, be intuitive and be reliable. (Not unusual for a woman, regarding computers or cars.) However, many of my colleagues are uber-geeks. Just being over 40 doesn't mean we can't handle the technology. We are just less patient of bad technology. I don't use the same phone I used in 1997, don't expect me to use an antiquated, poorly written program which was developed in 1997.
3--Another topic, but: Hospitalists are seeing patients because the primary care physician [PCP] chose that option. There are trade-offs for any system and thehospitalist system is no different. We may not have the longstanding relationships with people and families but we replace that with relationships forged under very emotional and intense circumstances. As with any physician, experiences vary greatly. You wouldn't slam all orthopedic surgeons because you had one bad experience or bad doctor, so you should not generalize one experience onto the whole specialty.
Also, the actual number of times people would actually see their PCP is lower than perceived, usually because of call schedules (seeing your doctor's partners instead) and going to hospitals where your PCP does not have privileges. I addition, your PCP is generally only in the house early morning and after office hours. When families come by in the middle of the day, I am available to talk to them. When someone crashes midday, I can handle it because I am there.
I got hugs from 2 patient families yesterday, one for spending the time to explain why the orthopedic surgeon was recommending an amputation ( he was at another hospital by the time the family got there) , another for transferring a patient after a terrible, prolonged, critical illness to rehab. Neither had PCP's on staff.
Short version: the biggest sellers are still the blandest water-beers (Bud Light as #1, Coors Light as #2); but those big sales are dropping fast. Meanwhile craft beers, of which Samuel Adams is by far the largest and Sierra Nevada #2, claim only a tiny sliver of the market but are the main category that's growing. You could view that tiny sliver—10 million cases a year for Sam Adams, versus 300 million (!) for Bud Light—as discouraging. Or you could use the increase for craft beers—Sam Adams up 11 percent last year, while Bud Light was down 1 percent—to give yourself heart. Myself, I always prefer to see the growler as half full rather than half empty.
I mention this to highlight John's post for anyone who might have missed it, and also as an excuse for some growler-half-full news I've meant to mention for months. Australia, which in most other ways has made itself into an astonishingly pleasurable food-and-drink paradise, has badly lagged in the beer department. Many Aussies are annoyed by the yokel image of their country conveyed by the Foster's "that's Australian for beer" commercials, although instead of yokel they would say "ocker." But weak and watery Foster's has been a fair representation of what the country's pubs generally* have had on offer.
[* Yes, yes, there have been exceptions. The Lord Nelson "Brewery Hotel" in Sydney, at right, is a place where I have spent an embarrassingly large percentage of my total time on Australian soil. Its Three Sheets Australian Pale Ale is my standard there. Plus, the MooBrew brewery in Tasmania, and some others—including the James Squire brewpub in the Salamanca area of Hobart, Tasmania, shown below. It's just that, compared with omnipresent good wines and great food, Aussie brews have fallen short.]
Until just now. The picture at the very top of this item shows an 11-beer range of craft beers. They run from Hop Hog IPA, made by the newish Feral Brewing Company in Western Australia (at far left), to Stowaway IPA from the better-known James Squire Brewery in New South Wales (at right). I bought all those bottles and lugged them home on a visit a few months ago to the wonderful Oak Barrel bottle shop in Sydney, below.
The "Aromatic Spelt Ale" in the middle of that 11-beer range turns out to be an acquired taste that I don't really want to acquire. Ugh! The other 10 were very impressive and have removed the only quality-of-life reason not to live in Australia. A recent local ranking put Feral's Hop Hog at the top.
The local press is carrying beer specials (right), and in general it is a great time to be an Aussie or visitor in search of non-watery beer.
But let's bring it back to John's post, and to what Deb Fallows and I have been discovering as we have prowled through smaller-town America. What is finally happening in Australia, and what everyone knows to have been happening for years in Oregon and Michigan and Vermont, is happening all over the place in the U.S. We've seen our share of truck stops and roadside convenience stores in recent months, and the selection there explains how those million-cases-per-day of Bud Light are being moved. But we've yet to be some place without its own startup brewery in the vicinity, or three or ten. Latest example: Georgia, source of the Terrapin brewery whose offering is shown below:
Each place we've visited, I've asked the young or more grizzled brewpub entrepreneurs how long this can go on. Indeed, it's conceivable that a world hops shortage could limit their growth—or, on the more positive side, blunt some of the trend toward super-hopped, too-alcoholic brews. But many of the brewers have pointed out that their share of the total market is so small that they could plausibly keep growing, even if the beer market as a whole, swill and all, is declining. Useful comparison: the "enormous" 11-percent growth in Sam Adams sales for one year was a total increase of about 1 million cases. The "tiny" 1-percent fall in Bud Light sales was three times as large.
So if tastes shift—and if hops remain—there is room for the craft brewers. Thus I cheer them on.
Reinvention and resilience across the nation Read more
If you're in Washington, please come by!
This evening I was looking through some of the pictures we have taken on these travels, to choose a few for a pre-program display. In the process I found some videos I hadn't been aware of, which Deb had taken from the right seat of the Cirrus SR-22 as we were flying around.
For an introduction to the concept of how the world looks different from 2,500 feet up, compared with either ground level or an airline altitude somewhere above 30,000 feet, here are a few minutes from the beginning and end of one flight. The first clip (with brief pre-roll) shows taxi and takeoff from runway 33 at KBTV, in Burlington, Vermont. About 35 seconds in you can see a big solar-panel array to the right of the runway. Then we head over toward Lake Champlain before turning left, to the south. You'll also notice a left crosswind: as soon as the wheels leave the ground, the plane is pushed over toward the right. (For aviation people: the departure instruction was "fly runway heading.") In the first few seconds, you'll hear a last pre-takeoff exchange of "Are you ready?" "Ready."
The second clip is about two hours later, as we were coming in for landing on runway 32 at KGAI, Montgomery County Airpark in Gaithersburg, Maryland, outside Washington. In the first 30 seconds you can see the runway off to the right, as we take a wide "right base" leg toward the airport. The plane then turns right to land.
Neither of these is offered as a pro-level video, or pro-level flying. They were opportunistic pictures Deb took en route. And the approach involved a much further-out base leg than is normal at this airport, because there had been some other traffic we were getting clear of. But that perspective allows a little longer-range view of how the runway looks from a distance, and together they may convey the sense of 3-D swimming through space that comes with small plane flight. Also, the background engine noise gives an idea of why we wear headsets in the plane.
UPDATE Thanks to the flight instructors and others who have pointed out that, among other possible technique-corrections, I should re-establish the habit of bringing the airplane to a full stop after it is on the taxiway and fully clear of the runway, to do a post-landing "cleanup." Flaps up, check lights and mixture, confirm a clear taxiway, and so on. That is correct -- even though this is an airport where I've landed hundreds upon hundreds of times, even though there is no control tower from which to get clearance or permission, even though I knew exactly how things were laid out and where I was going. One more item for the ever-sobering needed-improvement list. I appreciate the attention, reminders, and advice.
"Yes, there are problems in any technology implementation and there always will be. But fewer people die. Yes, it is important to connect with the patient. But fewer people die. Yes, the opportunity to pad billing is obscene. But fewer people die."
Dr. David Blumenthal, who now is head of the Commonwealth Fund, has been a friend since we both were teenagers. It was a sign of his medical / tech / policy skills that the newly arrived Obama administration put him in charge of encouraging a shift toward use of electronic medical records. It is evidence of his admirably good-humored big-tent personality that David still takes my calls after the many rounds of back-and-forth we've posted here in response to his original Q&A in our April issue, about why the shift has been so difficult and taken so long.
For those joining us late, you can check out installments one, two, three, four, and five. Herewith number six, on the particular question of how the non-expert public -- those of us who experience the medical system mainly as patients and bill-payers -- should assess the opinions of physicians, nurses, and other inside participants. Should we give them more weight, because of their first-hand expertise? Less weight, because of possible institutional bias or blind-spots? Both at once? See for yourself.
First, the concerns of two physicians. One on the West Coast writes:
I am a family practice physician in western Washington state. I have been practicing for 25 years. Ten years ago I was excited about about the potential of electronic technology to improve patient care. Today I am profoundly disappointed.
I am currently working in three different EHRs (electronic health records). Two are OK, i.e. allow me to efficiently document a patient visit with clinically relevant data. The other one is cumbersome beyond belief. It is a company with outstanding marketing capability that won over our administrators. It falls far short of meeting the needs of those of us trying to improve patient care. Intrinsically it fails to produce a note useful for other doctors. To achieve that end, I use time-consuming work arounds. Sad I think.
I believe that primary care is valuable to patients but also has potential to limit costs.....
I have included a reference to one of my favorite articles from the New England Journal of Medicine, including the first paragraph of the article:
"It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their 'civilian' life.
And from a doctor in Kentucky:
As a 50 y/o it infuriates me when I read that only physicians less than 40 are comfortable with EMR’s because they grew up with them. Well that’s crap. My first computer was a Commodore 64 which I learned to program. I am very familiar with computers and have 4 networked together in my home.
That being said I would agree with Dr. Wait [from this post] in that EMR’s are not ready for primetime. If EMR’s were so great, no one would have to bribe and penalize us to use less. They generate a tidal wave of information. The important data gets lost in the overwhelming volume of mostly useless information. I used to dictate my notes and they would then scanned into the computer. The note was legible and concise. I could find it anywhere. Then the EMR came. It takes 20 minutes to do what used to take 30 seconds. I get a note that is less than useful. It is full of errors that I can’t correct. Information that others have entered that is clearly wrong that I can’t remove. I no longer try. The only important part now of my notes are the HPI and the plan. The rest is just garbage.
To give you an example my EMR won’t let me enter a subtotal hysterectomy in the past surgical history. Even when I supply the correct CPT code the EMR calls this a Total hysterectomy, which is not correct and can lead to errors in determining who needs a pap smear.
So EMR remain not ready for primetime. I’m not sure why I can’t continue to dictate and allow the transcriptionist to fill in the EMR. It would work so much better.
Now for a different view, from an informed non-expert. This reader, a physics professor at a university in the South, uses the distinctive phrase of the day to suggest that we apply a discount to complaints from today's practitioners:
I've been reading the back and forth over electronic medical records. It seems the opposition comes, by and large, from doctors. Because why?
Because problems. There's lots of smoke and mirrors about interconnectivity, about interacting with the computer instead of the patient, about sleazy increased billing but all of that is in service of a single point of view: let's never change until we can change to something perfect. In other words, the underlying point is "don't make me change the way I'm used to doing things."
This all misses the main point. To me, what is overriding importance is the undeniable fact that ANY system that does NOT rely on the memory of the patient for long term medical history storage is NECESSARILY a better system no matter how badly it sucks. The VA has proved this over the last couple of decades as measured by the fact that fewer people die. Better information management beats clever doctoring every time.
Yes, there are problems in any technology implementation and there always will be. But fewer people die. Yes, it is important to connect with the patient. But fewer people die. Yes, the opportunity to pad billing is obscene. But fewer people die. Any large scale IT rollout has problems. The question is do the benefits outweigh the time invested in ironing out those problems. Most of us would say yes because fewer people die. I wonder why physicians are so reluctant to say that? Didn't they swear an oath or something?
I also wonder how many of these physicians, when directing their gimlet eye to another field such as public education, are equally skeptical of, say, massive online courses or teachers attending to the computer instead of their students, or teaching to the test? I somehow doubt it.
I think when you are the person dealing with a system day after day, it is easy to let your detailed knowledge of its problems overwhelm the vaguer notion of its benefits. You don't have a direct experience of a patient who didn't die, but you do have a direct experience of a technical snafu.
Thanks to experts and non-experts for writing in, and to David Blumenthal for opening this view into a world that affects us all.
Scene 1, from China this week. Thanks to many people there who sent me this news item and asked whether I had missed my historic chance:
A mysterious and debonair foreigner lands a plane on a road in Sichuan province, taxis over to a gas station and fills up, and then heads on his way. The Youku video below is in Chinese, but you'll get the idea. [Update there seems to be an intermittent loading issue on the Chinese side. If you don't see anything below, you can check the Youku video out here.]
More in English here and here. For me this is the path not taken. Background on China's aviation ambitions, and why they matter, here.
4) Scene 4, the small airport nearest you. A new company called OpenAirplane is trying to make itself the small-plane equivalent of the nation's car-rental network. The idea is that you get a "check-out" -- a test-flight with a company examiner to show that you can fly a certain kind of plane -- and then you are OKd to rent the company's planes around the country. This replaces the current system in which airplane renting is very rarely practical, since you have to get separately checked out at each airport where you might like to fly. More info here and here. This fits today's fly'n'drive scheme in that you could drive to an airport where you happened to be and then fly on.