Watch Live: The Washington Ideas Forum 2014

James Fallows

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. More

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.
  • The Electronic-Medical-Records Email of the Day, No. 1

    "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 onetwothreefourfive, 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.

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  • The Globalizing Golden Age of Beer

    The best side of America's influence on the world, and on itself

    Life in the Antipodes nears perfection. (James Fallows, in Sydney)

    John Tierney has put up an excellent and informative post today about the state of the American brewing market.

    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 Lightas discouraging. Or you could use the increase for craft beersSam Adams up 11 percent last year, while Bud Light was down 1 percentto 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.

    The Lord Nelson Brewery Hotel. I have a hundred
    pictures at this site.

    [* 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 othersincluding 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.

    Looking back toward the mainly craft-beer selection at Oak Barrel, via Google Earth.

    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.

    Feral Brewing Company, from Western Australia.

    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:

    From left: Glass from Fitger's Brewpub, in Duluth, Minn; Fresh Squeezed IPA, from Deschutes Brewery of Oregon; Hospecutioner, from Terrapin of Athens, Ga; glass from one of my spiritual homes, the Boxing Cat brewery of Shanghai PRC.

    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 growthor, 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 shiftand if hops remainthere is room for the craft brewers. Thus I cheer them on.

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  • Takeoff and Landing, From Inside the Cockpit

    The sense of 3-D swimming through space that comes with small plane flight.

    Somewhere in the Midwest, from 2500 feet up.

    On Wednesday night of this week, Deb Fallows and I are doing a program at Washington's historic Sixth and I synagogue, in conversation with the Atlantic's editor-in-chief James Bennet. We'll be talking about our American Futures project of learning about smaller American towns that are coping with economic or social dislocations. 

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    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.

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  • Your Linguistic Tour of the Okefenokee

    See if you can be Swampwise.

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    Deb Fallows, whose Twitter dispatches you can now follow via @FallowsDeb, has a new road-trip post available. It's on the linguistic aspects of the diction of the Okefenokee Swamp, and it is here.

    In the Vimeo clip below you'll see a  sample of what you'll find. Check it out!

     

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  • If Doctors Don't Like Electronic Medical Records, Should We Care?

    "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."

    How critics imagine the new record-keeping system. ( Wikimedia commons )

    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 onetwothree,  four, and fiveHerewith 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.

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  • Fly'n'Drive Notes From All Over

    Look! Right here on the road! It's an ... airplane.

    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.

    Scene 2, Holland. Last summer I mentioned an intriguing flying-car concept from Holland, the PAL-V.  Now the company says the device is on sale in Europe.  

    When someone gets one (it retails for >$400,000), please give me a ride. Thanks to reader EG; more at OZYBloomberg TV, and the company's news site. For good measure, here is its video too:

     

    3) Scene 3, somewhere in U.S military-contractor land. I offer you this:

    Hey, it can drive, and it can fly. Official name: the Black Knight Transformer (seriously). More details here. Thanks again to EG.

    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.

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  • The Seas? The Skies? The Transformation of a Company Town, Part 2

    One economic titan has fallen, another has taken its place, but a city wants to expand its options.

    The light blue shows ecologically valuable marshes and wetlands around St. Marys, Georgia, circled in red, and the Kings Bay naval base, east coast home of the U.S. ballistic-missile submarine fleet, in blue. ( Annotation of map from US Fish and Wildlife Service )

    The small town of St. Marys, Georgia, differs from the other places we have visited in the basic structure of its economy. When we first went there in the 1970s, it was still what it had been for many decades: a company town, in the good and (mostly) bad senses of that term. Now it is a variant of the same thing, and that is the circumstance the city and county officials are trying to change.

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    The good of the old company-town arrangement was that the giant mill of the Gilman Paper Company provided paychecks for the overwhelming majority of families in the area. Indeed, the air and water pollution was so heavy, and the location was so remote, that a job with Gilman was the most obvious reason anyone would choose to live there. And not to belabor the bad -- if you want belaboring, check out this previous post -- but in addition to the normal distortions of a town all-dependent on one company and the people who ran it, the company badly abused its power in environmental and political ways, including hiring a hit man in a failed attempt to eliminate a local critic -- that critic being a man who became our friend, Wyman Westberry. 

    That was then. Largely through mismanagement and the side effects of family squabbles, Gilman went through a long decline. You can read some of the details in this Forbes account, but overall it was a depressing personal and business saga. (Some other, better run plants still operate in the vicinity -- you can just glimpse them in the distance in this shot below, from the former Gilman property across the wetlands toward the coast.) Gilman had been the largest privately owned paper mill in America, but 15 years ago the family sold it to a Mexican firm, and not long afterwards that firm closed the mill, eliminating some 900 jobs.  

    In 2007, the remains of the mill were blown up, despite some local efforts to retain and reuse them as startup sites, light-industrial buildings, or even monuments. That left what is now a rubble-filled "brownfield" between the city's historic downtown and the coastal marsh. Here is a video of the demolition (in the last few minutes of the clip), with others here and here.

    Part of today's post-demolition Gilman ruins:

    The good news for St. Marys and surrounding Camden County was that another mammoth employer had arrived even before Gilman went down. That was the US Navy. During the administration of the former submarine officer and former Georgia governor Jimmy Carter, and with Georgia Senators Sam Nunn and Herman Talmadge then big powers on Capitol Hill, the U.S. Navy decided that Kings Bay, immediately north of St. Marys, would be the East Coast home of America's nuclear-submarine fleet. (The West Coast home is near Seattle.)

    That big news of January, 1978, is memorialized in a front page shown in the local Submarine Museum (at right). Everything about the city was changed by the Navy's arrival. In Gilman's heyday, its manager had claimed that 75 percent of the people in the county owed their living directly to the mill. A few weeks ago in St. Marys, local officials told us that perhaps 70 percent of the regional economy was now related to the base -- a figure that includes rental housing, retail, construction, and the other spillover effects of growth itself.

    I'll save for an upcoming installment some of the social, cultural, and political effects of a large military presence in a small Southern town like this. For the moment, the point is the part of the local economy that did not change, which was the outsized importance of a single big-gorilla economic engine. 

    Gilman Paper Company, the previous gorilla, had been "local" but not in a good way. The local managers behaved as mini-tyrants (if you don't believe me, believe the state and federal prosecutors who went after them), and the owners lived in New York City and seemed to view the mill mostly as a hinterland source of wealth. Their ongoing source of local investment was a resort plantation where artists and ballet figures, notably including Baryshnikov, vacationed and trained.

    The U.S. Navy, the current gorilla, is by all accounts faultlessly well-behaved and good-citizen-like in its local relations. The submarine officers and seamen are an elite within the military -- older, better educated, and more carefully selected than the norm, and not any source of trouble in town. But by definition a military presence is transient -- and while some Navy officials come back to the area after retirement, the Navy represents an economic power that is in but not of the town. Much of the growth it has induced as been "just" growth -- malls, restaurants, fast food, etc on the fringes of town. (This ingenious "swipe map," by our John Tierney and David Asbury of Esri, lets you compare the 1990 and 2010 land-use patterns, given a sense of the strip-mall development around the Navy base and an I-95 exist.)  

    We were struck by how different this single-source dependance was from other places we have seen. Sioux Falls has a big financial-services industry -- but also is a major retail and medical center, and has universities, and has growing high-tech sector, to say nothing of its huge agricultural businesses. Greenville used to be textile-dependent but now has automotive and other manufacturers, plus finance and services,  plus a vibrant downtown, plus tourism and universities etc. Eastport is scrambling to create more of everything but is not reliant on any one thing. With variations, the resilience-through-diversification saga is also true of Redlands, Burlington, Holland, Rapid City, Winters (about which more soon), and other places we have seen.

    The officials we met from St. Marys and Camden County are perfectly well aware of the imbalanced nature of the local economy. One school official described it, during the Gilman era, as the "Uncle Bubba" phenomenon. "If a kid was slacking off in school, you couldn't tell him to try harder, because he'd just say, 'My uncle Bubba will get me a job at the mill.'" Uncle Bubba can't get people into the Navy, but another person said: "Most places talked about economic development, but we really didn’t need to worry about that. Around the time Kings Bay leveled off, the housing industry started to grow. We kind of thought, well, we don’t need traditional economic development. We kind of got our eyes off the ball." But now, he said, "We have looked in the mirror and, for the first time in my life, found the political will to pull together."

    People in the city said they are trying to think about using things they do have, to foster the growth of what they now lack. The things they have fall mainly into these categories:

    - Environmental plusses in the narrow sense: It's a pretty downtown, which resembles better-known and more popular resort cities but with dramatically lower real estate costs. Tourists now troop into St. Marys for holiday celebrations (or sail in, along the Intracoastal Waterway), and to take the ferry over to the Cumberland Island National Seashore, historically a resort for the Carnegie family. So plans are underway to add to attractions, hotels, and other local life that would entice people to stay for a day or two rather than just pass through.

    - Environmental plusses in the broader sense. The Fish and Wildlife Service map at the top of this item gives a hint of what is true for strikingly large stretches of the Georgia coast. Of the entire Atlantic seaboard, it's one of the best-preserved and most beautiful parts, in addition to having great ecological significance for its wetlands. Beautiful places, especially by the coast, are increasingly where people with a choice of where to live, want to live. You can rebuild infrastructure but you can't manufacture an ocean view. (Well, I've seen attempts in China, but you know what I mean.)

    -- Filling an educational hole. Camden County has a very impressive "career technical" high school, as noted before. It does not have any well-established post-secondary system. So a push is on to use public land to build a tech-related college, in hopes that this will be the next step in creating the educational / cultural environment in which new businesses might start, and toward which talented young people might be drawn.

    -- And looking toward space. The commercial space-launch business is growing. According to local officials, this part of Georgia was in the running when Cape Canaveral was chosen as NASA's main site in the mid-20th century. And so they are making a 21st-century push to build a new "spaceport" in a former industrial area (and one-time Thiokol rocket-test site) just north of town, where companies like SpaceX would be able to launch their vehicles.

    The first fundamental truth of rocketry is that the closer a launch site is to the equator, the greater the free boost it gets from the Earth's rotational speed. A related truth is that it's better to launch rockets over the ocean than over populated land. Camden County has just now received a report from a Georgia Tech team headed by professor Robert Braun, a NASA veteran, on the advantages this means for its location. For instance:

    Launches from Camden County have the capability to fly due east, maximizing the velocity boost from the rotation of the Earth and enabling more payload to reach orbit. The Camden County’s southerly location provides launch vehicles with an extra boost from the rotation of the Earth when reaching orbit. The Camden County latitude provides a 8% velocity advantage due to the Earth’s rotation relative to the Wallops Flight Facility [in Virginia] and a 4% advantage relative to Vandenberg Air Force Base [in California]. 

    One of the most-touted recent spaceport possibilities is near Brownsville in southernmost Texas. Thus this compare-and-contrast chart from the Georgia Tech paper:

    This is certainly enough for now. I'll have a little more to say about the marshlands, and the space plans, and the local leadership later on. For the moment, here is how this fits into what we've seen elsewhere across America: even in a place that for now enjoys the benefits of a dominant, not-about-to-leave-town local employer, people clearly see the need to invent a new future for themselves, and are trying everything they can.

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  • Heartbleed Update: Sites That Tell You Which Passwords You Should Bother to Change

    Your two-point to-do list for the weekend.

    [Update: see bonus xkcd link below.] For background, see this early Heartbleed dispatch on general principles of password hygiene, and this one on a range of test utilities to check whether possibly affected sites have yet been repaired.

    Your simple two-point checklist for today and the weekend:

    1) In addition to some of the other test sites already mentioned (at LastPass, Possible.lv, Qualys, Filippo.io), check out the very convenient guide provided by the security firm IVPN. Here is a sample of what it displays:

    It doesn't cover all sites, of course, but it includes many of the biggest-volume ones. The two most useful aspects of this presentation are showing which sites did not use OpenSSL at all and thus were not affected; and clarifying which affected ones have already implemented a fix, so that new, changed passwords will "stick." I can't independently vouch for all the reports here, but the ones I do know about match up with what I've seen elsewhere. Again, the advantage here is the simple clarity of the presentation.

    2)  As this episode recedes and tech people figure out its long-term implications, commit to heart the Basic Rules of Password Life, as reeled off and explained in the initial post:  

    • Err on the side of changing passwords, especially after reports like this;
    • For sites you care about, never use a password you have ever used anywhere else;
    • Use a password manager to avoid going crazy from the previous two tips;
    • Use two-step security systems when they're available, for example in Gmail;
    • Remind yourself why it's worth going to this bother by reading what can happen if you don't. And anyway, that report is interesting.  

    That is all. Again, the upshot of recent reports is that most important sites have now patched their OpenSSL vulnerabilities, so there's no further excuse for putting off password changes where indicated. 

    Update: xkcd has a wonderful visual explanation of how the bug actually works.

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  • St. Marys Interlude: The Okefenokee

    Ever wondered what one of America's most famous swamps looks like? Wonder no more.

    In the Okefenokee Swamp (James Fallows)
    Inside Marriage Special Report bug
    Reinvention and resilience across the nation
    Read more

    When we have told people who are not from Georgia that St. Marys, where we spent time last month, adjoins the Okefenokee Swamp, the most typical reaction has been: I've always wanted to see the Okefenokee!

    Same on our side. We missed it during our visits to this region during the 1970s. Last month, with prominent local citizen Wyman Westberry, we spent a day at the Okefenokee, whose Waycross entrance is not far east of St. Marys. This is how it looks.

    The "blackwater" of the swamp, due to tannins leaching from the vegetation:

    Although black, the water is clear and clean, and reflective, and hosts wildlife. Including this baby.

    Another illustration of the reflectivity, and the general effect:

    And a reflectivity gimmick:

    At tree level, an infinity of Spanish moss:

    From above-treetop-level, the effects of many dry years (although many of the leafless trees in the foreground are deciduous trees that had not yet leafed out):

    Plus animals fictional:

    And real. These were not babies. The smallest was about the same size as me.

    Meanwhile, today on our partner Marketplace's broadcast, Kai Ryssdal had a very nice interview with Deb Fallows, shown here in the Okefenokee, about the subject of one of her previous posts: the complex embedded meanings of the questions you ask strangers on first being introduced. It was also the subject of a nice presentation by the Atlantic's video team, here.

    So if you are wondering what the Okefenokee looks like, this gives you a start. Tomorrow, more on the complex economic ambitions of the small neighboring town of St. Marys, and how they can match the  accomplishments of its impressive county-wide high school.

     

     

     

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  • How to Check If a Site Is Safe From 'Heartbleed'

    If your site reads Safe, it makes sense to change your password. Even if it doesn't yet, a change still makes sense.

    This post follows one a few hours ago about the Heartbleed security failure, and for safety's sake it repeats information I have added to that post as an update.

    Point 1: If you would like to test to see whether a site is exposed to the loophole created (over the past two years) by the OpenSSL bug, you can go here and enter the URL you are concerned about. (This tip via Bruce Schneier.) As explained in the FAQ, the test sometimes delivers "false positives" for vulnerability  -- that is, it may report problems with a site that actually is OK, or that is in the middle of taking steps to protect itself. But the site's creator explains why "false negatives" -- OK signals when there actually is a problem -- should be very rare, and especially if you perform the test several times. Update Here is another good test site.

    Point 2: If a site tests through as Safe, then it makes sense to change your password there. And all of my email and financial sites are now saying Safe, so the changes I am making there will stick.

    But even if a site does not say Safe, the people I have asked say that it still makes sense to change -- even though you'll need to change again when the SSL for that site is fully repaired.

    Reasoning: If you change it now, it's possible that a still-active hacker will capture info today. But if you don't change it now, anything exploited in the past two years is vulnerable. Also, many sites that are not yet fully protected are on higher alert than they would have been before this news, so hackers may have a tougher time in the new environment than when this was an unknown-unknown.

    Point 3: The guy who created the test site, a young Italian cryptologist based in Milan, has a donation button on the site.

    UPDATE: Here is another industrial-strength test site. I tried the same domain on it, and the score you see here is way, way close to the top of those it has tried. And here is another test site.

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  • The 5 Things to Do About the New Heartbleed Bug

    Should you take the latest security scare seriously? I do, and here are the steps I am taking.

    [Please see important UPDATE in a newer post, and repeated at the bottom of this post.] Most flaps about scary new Internet bugs are just typical scary Internet flaps. This latest one, the Heartbleed bug, I am taking seriously. Potentially it means that username/ password combos for the sites everyone considered secure have in fact been hacked and stolen.

    Update: Just this second, I see that Bruce Schneier has declared the bug "catastrophic." Consider yourself warned. Schneier adds:"On the scale of 1 to 10, this is an 11." He has no track record as an alarmist.

     You can read more about how it happened, and why it matters, at this helpful master site and the dozens of useful tech links it includes. Here is also an overview from TechCrunch. (Update: and here is one of several useful test facilities to let you check the status of sites you're concerned about.)

    Simplest way to understand the problem: one of the protocols that many sites use to protect their own security, in an implementation known as OpenSSL (for Secure Socket Layers), itself has a previously unknown bug. That bug, in place for the past two years, could in theory allow an attacker to harvest large amounts of name/password combos plus other info from sites believed to be perfectly safe. Because exploitation of the bug would have left no trace, no one (except a potential hacker) yet knows how many names have been taken, or from where.

    A patched OpenSSL version exists and is being deployed. Until then, what should you do? Here's a five-point checklist, followed by explanations.

    1. Change the passwords for the handful of sites that really matter to you. I'll explain how you can do this in a total of ten minutes or less. This probably isn't necessary, but just in case...
       
    2. Do not ever use the same password at two sites that matter to you. Ever. Heartbleed or not, this lowers the security level of any site with that password to the level of the sleaziest and least-secure site where you've ever used it. 
       
    3. Use a password manager, which can generate an unlimited set of unique, "difficult" passwords and remember them for you.
       
    4. Use "two-step" sign-in processes wherever they're available, starting with Gmail.
       
    5. Read what happened in our family three years ago, when one of our Gmail accounts was taken over by someone in Africa, if you would like a real-world demonstration of why you should take these warnings seriously. It's from an article called "Hacked."  

    That's the action plan. Now the details.


    What I am personally doing about Heartbleed, and why.

    -  I am changing my password for a handful of "important" sites. My finance-related sites: bank accounts, credit cards, mortgage-payment, investment accounts. The email accounts I actually use, three of them in total and all Gmail-based. Plus all social-media accounts. Even though on most of these accounts I am dormant rather than active, I'd rather not have someone take over the account and cause problems in that way.  (UPDATE: In response to questions, you would need to do this again once the OpenSSL patch has been distributed or the sites have in other ways confirmed their safety. Nonetheless it seems worth doing even now, even given the possibility that a site is still vulnerable and could have new info intercepted as you're changing it, because otherwise you're exposed to any info collected over the past two years.)

    - I am abiding by the watchword of never using the same password on two accounts that matter. Whoever is in charge of security at, say, HottestCheerleadersPlusCheapMedicineFromThailand.com (not an actual site I have visited) might not know how to protect against hacks, or might even dishonestly sell its user info to hackers. They could then blindly try the combos elsewhere.

    - I am making all this easy on myself by using a password manager. The one I have used and liked for several years is LastPass, which was also the top choice in this recent PC Mag review. You can read reviews of a wide range of alternatives here and here. The idea behind all of them is that they store a vast range of passwords you could not possibly remember yourself; they automatically fill them in for your sites; and they have a range of very tough security measures to protect this precious central vault. In well under 1 minute per site, I can have Last Pass generate a new, "difficult," never-before-used password for important sites -- let's say u!YKhtAs7xQA , though that's not a real one -- and set my systems up to use that automatically.

    For now I'm not getting into the conceptual question of whether one centralized password trove is theoretically more vulnerable than the "distributed" approach of trying to manage this all on your own. In reality, I'm convinced that it's better to use a password manager, and safer than the alternative of trying to keep track of a whole list of passwords on your own. (For instance, you can read Last Pass's explanation of how it does encryption right on each user's computer, not at the central site, so that even someone who got the main controls wouldn't know your passwords.) The only password I keep in my mind is a very long password for Last Pass itself. It's so long that it could never be cracked by brute force, much as no one will win Warren Buffett's billion-dollar bet on the NCAA tournament. But it's very easy for me to remember, because it's a long passage I can reel off by heart.

    -- I am using two-step sign-in processes for every system that allows them, and you should too. Gmail does this, and in fact pioneered this as a free feature for mass, non-commercial users. Last Pass also does so. How this works: In certain circumstances, logging in requires not simply your password but an extra, real-time code that is sent to or generated by your mobile phone or other device. What it means: For all practical purposes, someone cannot take over your account from afar. Since so many destructive scams and hacks are carried out remotely -- from Russia, China, West Africa, Israel, the Stans, you name it -- this is the easiest possible protection you can take against a very broad category of attack.

    Two-step systems can be mildly inconvenient, but a lot of that has been buffed away. For instance, you can set Gmail so that it doesn't need the second password as long as you are using your own computer or phone. For more details, see this and this

    More as the story develops. The point for now: none of us can do anything about larger architectural questions of security, surveillance, vulnerability, and so on for the Internet. But along the spectrum of what that architecture makes possible, we can make ourselves less rather than more vulnerable. These steps will help.


    Update: Via Bruce Schneier, it is very much worth checking out this test site, to see whether a site you deal with frequently has been repaired to avoid the SSL bug. For instance, here -- fortunately -- is what you would see for the Atlantic's site:

    In theory, changing a password on a not-yet-fixed site could create new vulnerability, if a hacker has just decided to start watching it today. In practice, most of the people I have checked with say it's worth doing, because otherwise you're exposed to anything captured within the past two years. Then, when a site becomes safe -- as shown above -- it certainly makes sense to change the password. For further explanation, see this follow-on post

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  • What an Autopilot Could Never Do

    Fun with flying, extreme crosswinds edition.

    Last week I posted a video of airliners whose pilots skillfully executed the "crab into kick" technique for landing in a crosswind. As a reminder: the airplane approaches the runway at a "crab" angle, to offset the wind and keep its heading lined up with the runway. Then, when the wheels are just a few feet above the ground, the pilot "kicks" the airplane's own axis into alignment with the runway (so sideways force doesn't shear off the wheels when they touch down), with pressure on the rudder.

    Now some illustrations of how things look if the wind is even stronger and gustier. These take-offs and landings, and numerous "go-arounds," were filmed this winter at Birmingham airport in England, under what were evidently extremely gusty conditions. The wind's strength is one challenge. The continual changes in strength -- the gusts -- are the real problem.

    Whoa. This is the kind of thing no autopilot could ever handle. Thanks to reader BB for the tip.

    And great camerawork, by the way. Also, I know that the camera angle foreshortens things, so it can look as if the planes are descending helicopter-style. Still, that runway is impressively hilly. For instance, as shown in the approach starting at time 6:00. 

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  • But Seriously Now, Why Do Doctors Still Make You Fill Out Forms on Clipboards?

    "Meditative practices emphasize returning to one’s breath. The clinical equivalent of this is to return to one’s patient. "

    Growth of "Hospitalists," a relatively new medical specialty discussed in the last note below. ( Society of Hospital Medicine )

    We'll get back to St. Marys, Georgia, later today. For now, let's dip back into the mailbag for the latest array of views -- most from doctors or other medical professionals, some from technologists, some from "ordinary" patients -- on the pluses and minuses of the shift to electronic medical records. For background: my original Q&A with Dr. David Blumenthal, who directed the electronic-records program at the start of the Obama administration. That article also has links to four previous rounds of discussion -- and, why not, here they are again. One, two, three, and four. Now, eight more ways of looking at electronic medical records.

    1) "Unremitting folly" and "lack of leadership," and apart from that it has some problems. A negative verdict:

    I am a recently retired family physician and was formerly a physicist. Fifty years ago I was programming a mainframe computer in Fortran and am currently using the Python language to pursue several interests. I have experience with 4 different EHRs. Though not a computer expert, I am neither a technophobe nor a Luddite. 

    My purpose in writing to you is to draw your attention to the elephant in the room. In brief, the rollout of electronic health records (“EHRs”) in the United States is a story of unremitting folly, lack of leadership, opportunities wasted, and a stiff dose of medical academic hubris.

    Anyone involved with medicine or information technology (“IT”) has surely been aware for 3 decades or more that EHRs were coming, someday, somehow. The potential advantages were always clear enough. Broadly speaking, they were ready access to individual patient data at the point of care and aggregated patient data, “big data", to be mined somehow for new medical knowledge.

    Standards for medical records were developed, but were overly broad and insufficiently specific (see, for example, HL-7).  The Department of Defense and the Department of Veteran Affairs were interested in developing a systems-wide EHR, which probably discouraged any entrepreneur reluctant to develop a product only to see the government version become a national standard. 

    The lack of a clear standard is a major issue. EHRs, like computer operating systems, are a highly path-dependent technology.  The system you buy today will be yours to live with for the next 20 years, even if no system available today meets your needs.  A good example of this path dependence is the history of Unix-like versus Microsoft versus Apple operating systems.  Unfortunately, the EHR mandate ignores the lesson.

    We now see a technology not ready for deployment being imposed on hospitals and other health care systems. They can buy in with some help from the federal treasury or wait and be penalized for not being on line, an interesting new form of under funded federal mandate. Health care systems are scrambling to enlarge IT departments. Different vendors’ systems are largely not interoperable. This is more than a nuisance when patients self-refer between health care providers.

    For a physician seeing patients in clinic an EHR can be an astonishing impediment. We are rebuked, often deservedly, for being insufficiently engaged with our patients, yet now must spend more time in front of computer displays. (“Why can’t I find a nurse? They are in the patients’ rooms because the computer system is down.”)  

    The practice of medicine involves intensely personal encounters; indeed the patient-physician relationship is what makes being a primary care physician such a privilege.  The EHR does not accommodate narrative analysis of a patient encounter, also known as the personal touch. 

    Voice recognition requires time-consuming, highly distracting concurrent proofreading, quite unlike dictation transcribed by human intelligence.  

    Examination rooms are small (and are not going to grow), requiring that the physician’s back be toward the patient when addressing the computer. [JF note: several previous reader-messages have suggested solutions to this problem.] In the examination room the EHR is marginally effective and utterly inefficient. The human-machine interface is crude and by itself should have precluded widespread deployment of EHRs at this time. 

    EHRs have real potential for “encouraging” adherence to guidelines purported to improve “quality of care.” This is at best a mixed blessing. Many, probably most, guidelines are not solidly grounded in evidence or serve the self-interests of their authors. Until the guidelines industry is brought to heel, patients are at risk of negative benefit.  The diabetes-industrial complex is a good illustration of this. 

    The entire history of EHRs in the United States is worthy of a full-length book. An overdue technology, it is here to stay, as it should.  However, the fact remains that it was overpromised and recklessly deployed.  There are lessons to be learned, if and only if analyzed and reported by persons without a personal stake in the matter.

    2) "A patient's visit to the doctor is morphing into a billing session." From another practitioner:

    Maybe I’m late to the party here, but I thought I’d add a few additional perspectives regarding the matter of electronic medical record systems (EMRs).

    First, the good: A tremendous upside to EMRs is that they make the record so easily accessible. When I was a resident, I seemingly spent half of my time running around the hospital searching for patient charts and scans. Scans were the most maddening—the radiology file room was far from where my patients mostly were. Often, the file clerk wasn’t there. Other times, there were several teams ahead of me, and I’d waste 20 minutes standing there waiting for my turn. And then the scan may or may not even have been there—another team may have checked it out and taken it to their work room or the operating room.

    At my current institution (a large academic center) all of our scans are digital and can be viewed from any terminal in the complex and, via an encrypted connection, from any internet-connected computer anywhere. If one of my residents or a radiologist calls me regarding an important finding, I can be looking at the images and discussing the case in under a minute. I can show the images to colleagues, display them at a teaching conference, and use them to educate the patient and his family without worrying whether I’ll be able to get my hands on the films when I need them and without impeding anyone else’s access.

    Now the bad: Others have mentioned that EMRs make it easier to bill for higher levels of service. The larger issue is that, sadly, the patient’s visit to the doctor is morphing into a billing exercise with a clinical encounter appended to it. EMRs facilitate this process, but I think the causes lie upstream—with physicians, with the hospitals that increasingly employ us, and with our political choice to largely preserve a fee-for-service medical system.

    More recently, the billing imperative has been joined by the safety and quality imperatives. These are sorely needed, but they do sometimes distort medical practice and can even strain the doctor-patient relationship. Again, EMRs potentiate this but aren’t the cause. For example, one commonly used quality metric is a hospital or program’s ratio of observed to expected mortality. The numerator is straightforward, but arriving at the denominator requires prognostication based on the patients’ ages and the number, type, and severity of their various morbidities. Just as EMRs make it easier to document in such a way as to capture the highest possible charges, they also make it easier to document in such a way as to portray the highest possible severity of illness (and hence mortality risk). The hospital’s coders are constantly asking me to clarify various diagnoses that are unrelated to the patient’s presentation and that are often outside of my area of expertise. This diverts my attention away from direct patient care and instead toward the practice of massaging electronic medical records in order to optimize mortality ratios.

    For many physicians, the result of this pivot away from the individual patient and his clinical needs and toward the increasingly complex documentation of such is that medicine ceases to be an emotionally and intellectually fulfilling practice and becomes instead clerical work. We no longer spend a few extra minutes getting to know the patient and his family, perhaps learning something seemingly small but ultimately clinically important in the process. We instead spend unsatisfying time asking irrelevant questions (the review of systems) that allow us to check more boxes, bill a higher level of service, and make the patient appear as sick as possible.

    There’s a mental antidote to this pessimistic mindset, which is easier said than done given the cognitive loads under which we all labor—loads that are increased not only by the demands of using EMRs, but also by pagers, cell phones, various inboxes, etc. The antidote is to listen deeply and re-connect with the person in front of you. Meditative practices emphasize returning to one’s breath. The clinical equivalent of this is to return to one’s patient. A corollary to this is that my generation of medical educators, witnessing the end of the paper chart era while having many years of service ahead, must practice and teach the fundamentals of clinical medicine while helping trainees learn to marshal EMRs and other technologies appropriately.

    3) Comparison from France, and from Seattle

    Quote from one of your other readers: "[At] Group Health Cooperative in Puget Sound, electronic medical records were adopted decades ago, and are widely used and highly effective."

    Response: When I lost my insurance and the ability to stay with Group Health, I wanted to take my medical records. But they charged $45 to put them on a CD. Inexcusable even five years ago. They could just as easily have written a simple program to route records to a printer and handed me the stack of paper at nearly zero cost. Let alone providing the option to buy a USB stick for $5, with all records on it.... 

    Of (possible) interest: "The French way of cancer treatment", by Anya Schiffrin, from February 12, 2014.

    "In New York, my father, my mother and I would go to Sloan Kettering every Tuesday around 9:30 a.m. and wind up spending the entire day...feeling woozy, we'd get home by about 5:30 p.m.

    "[In Paris] A nurse would come to the house two days before my dad's treatment day to take his blood. When my dad appeared at the hospital, they were ready for him. The room was a little worn and there was often someone else in the next bed but, most important, there was no waiting. Total time at the Paris hospital each week: 90 minutes."...

    "When my dad needed to see specialists, for example...the specialists would all come to him. The team approach meant the nutritionist, oncologist, general practitioner and pharmacist spoke to each other and coordinated his care. As my dad said, 'It turns out there are solutions for the all the things we put up with in New York and accept as normal.' "

    Competition cannot provide these results, nor any market forces whatsoever. Regarding people as fellow humans can.

    4) And from Vietnam:

    [How it works there.] Go to the doctor. Begin the discussion at his/her desk. Your previous records have been reviewed in the data base. The doctor's hands rest on the desk.  She/he looks you in the eye and asks questions. Diagnosis made. Treatment recommended. If prescriptions are needed, they are input and transmitted electronically to the receptionist and the pharmacy. You make your co-pay pick up your drugs and depart.

    The efficiency is remarkable. I once had a CT scan at a gigantic clinic with a branch here and in California. The radiologist finished and said

    "Go get a cup of coffee and come back. I'll have your films in half an hour."

    EMR is a tool. A hammer is a tool. In the hands of persons with evil or avaricious intent, either one can do tremendous damage.

    5)  And Boston:

    About 4 years ago I changed health insurance plans and moved my business to a doctor who was a member of Partners Healthcare in the Boston area. I eventually discovered that the practice was connected to a medical records system that would allow any practitioner connected to that system to have immediate access to doctor’s notes, lab results, etc. related to my care. I could also email doctors, make appointments, obtain referrals, request subscriptions over the internet. I grew very comfortable with this. 

    Then my wife had a brain seizure and the EMTs took her to the nearest hospital. The hospital and the doctors who worked at that hospital were not connected to the EMR system we had been using. Problems ensued. 

    The hospital had no access to her history of care.

    I had to track down a doctor on a Sunday night and request complete information about my wife’s medications. The doctor had to send an email to my cell phone so that I could verbally communicate this critical information to the attending physician. 

    Drastic changes in medication were made with negative consequences. 

    I had not realized how much better care could be when you are using doctors who have access to an EMR system. But it is important that every doctor and hospital you use be connected to that system. 

    I will not consider using any medical service that is not connected to this EMR system in our area.

    6) And from a doctor's perspective in Boston:

    I am a surgeon who practiced in a solo private practice in a low income area in Massachusetts for 30 years. I bought an EHR in 2011 and participated in the incentive payment program from CMS and a subsequent audit in which the payment was recouped.

    As other physicians have pointed out , the EHR increased my workload by at least 20%.Dr Blumenthal and his team could have worked to make the VA EHR system, that the taxpayers paid to develop, available universally. Instead perhaps thousands of vendors were certified by the government . The price of these systems was always magically about the same: the $45000 in incentive payments that were promised by the CMS over 5 years.

    Once purchased, myriad other charges arose. The systems were clearly designed to maximize billing through justifying documentation modules. They also were set up to create reports to be forwarded to the government regarding "quality of practice." These mostly involved fairly crude measures like  bean counting how many patients had mammograms or colonoscopies.  With all this crammed in, the goal of creating  clear, informative documentation across a variety of specialties was bound to be lost .

    When these systems failed to serve particular practices or specialties well, , physicians were encouraged to develop their own templates and modifications. More time away from patient care and expense loomed.

    In Boston, there are three major hospital and physician practice systems based on the three medical schools: Tufts, Harvard, and BU. When a patient gets chest pain acutely , he will be taken by ambulance to the nearest facility.He may be transferred during his treatment to a different facility that may or may not be part of the hospital system where he was initially brought. His subsequent outpatient may again be not necessarily with physicians who work for the hospital system where he was treated. It is very likely that the various computer systems involved with the documentation of his care have no interconnectivity.

    At one of the many dinner meetings that we were invited to in 2010 and 2011 exhorting us to adopt the EHR , I queried an employee of the Mass ecolloborative, a federal  grant funded entity, about what priority CMS and the government were giving to the issue of interconnectivity. It seemed unlikely that the big, fiercely competitive  hospital systems and  the IT vendors would pursue this on their own . I specifically asked, when would an ER doctor seeing a patient at BU be able to see the records of the patient's previous care at Tufts or Harvard and she shook her head. So I ask if it would be in five years and she shook her head again . I tried ten years and she said "maybe" and then ,on prompting, said "they are talking about this."

    It seems: you are what you mandate, and the approach of Dr Blumenthal and his team, in my view, has  endorsed and augmented the free market model as regards IT and the large hospital chains and their internecine rivalries. The consequences to patients and independent practitioners are enfolding .

    So, what's a patient to do? In China, in the barefoot doctor days, they gave the paper charts to the patients  and let them carry them around.Not unlike in  the third world, many of my low income patients have smart phone access. In France, as TR Reid has reported, you can go to a doctor in their system and put your ID card through their reader and your updated EHR can be read off your chip. Patients need apps that can download and store these various differently configured EHRs. Like a lot of things regarding your health, when patients are empowered, things really can change.

    7) The technology has problems similar to the Pentagon's:

    1. Yes, some of the large health care systems such as Kaiser Permanente have deployed relatively effective electronic health record systems but what is seldom discussed are the huge cost-overruns associated with these deployments. 

    Health care IT procurement in the large delivery systems is similar to the problems that the Pentagon experiences when it buys weapons systems---the systems usually work, but the costs are often much higher than expected (therefore, the net benefits are lower than expected).  This problem is not unique to the health care sector---as you know, development and installation of enterprise software systems is notoriously complex and even some of the most IT savvy corporations and government agencies have experienced huge cost overruns and outright failures in this area. 

    Unfortunately, there is sort of a conspiracy of silence in the health care sector about cost overruns.  Both the software vendors and the executives who run these organizations are loathe to acknowledge this problem, instead they would rather focus on the benefits (which to be sure are real in many instances) and not talk about the costs---for example, Kaiser Permanente's staff has published 3 books touting the benefits of its electronic health records system, but none of the books discuss the costs or many of the daunting technical and organizational challenges they confronted in building their system.  

    2.  The interoperability problem in health care IT has two dimensions.  The first dimension (and the one that gets the most attention) is the lack of interoperability across health care organizations (as noted by the one of the physicians who commented on the VA's system).  The other dimension, which receives relatively little attention, is the lack of interoperability within organizations. 

    Most large health care delivery organizations decide to keep some of their legacy systems when they decide to implement a new EHR---for example, they may decide to keep their existing radiology and lab order systems, which means they have to spend alot of money creating middleware that can facilitate communication between the old systems and the new EHR.  The cost of developing the middleware is often huge because of the absense of industry standards---this is major reason why cost overruns in this space are so common.

    8) And to round things out, illustrating the complexity of working any change in today's health-care system, the complicating fact of that rapidly growing medical specialty, the "hospitalist":

    After years of only needing to see my doctor (the same one since 1977 until 2013) I've had an up close and personal experience with the new system that has required new doctors (a new medical condition and the retirement of my family physician). 

    What has that meant to me as a patient?  Like the doctor you quoted, when I see my new family physician (still the same practice that is the home of thirty some years of handwritten charts), she is looking at the computer instead of me.  She's also asking the same redundant questions over and over again.  There is a third party in the room--the computer--that is getting the major share of the attention. 

    On the other hand, I love having prescriptions entered immediately.  The scary part: I have caught a number of mistakes: which prescriptions I'm actually taking, what the dosages are, what diagnoses I've had in the distant past at another medical facility.  As they say: garbage in, garbage out. The only good thing is that people are mentioning the "garbage" and asking me if it is true because it is more obvious.

    But the computer is just one part of the problem.  Here's a much scarier thing.  An elderly man with Parkinson's is admitted for emergency surgery that has nothing to do with the Parkinson's.  He suffers from constipation--a common side effect of the disease.  He has a regular routine of over the counter medication to help with the problem.  His wife explains to the medical staff that this is what is prescribed by his regular physician. 

    But his care is now overseen by a hospitalist.  His wife is told that the constipation issue is being handled as usual.  It isn't.  After five days, he is extremely bloated and uncomfortable and nothing has been done.  His wife pleads for help for him in the form of an enema. Did I mention that she is the kind of person who doesn't like to be demanding? The hospitalist (who has almost never visited him and operates through the computer and the nursing staff) orders an x ray and then an enhanced x ray.  Meanwhile the patient gets more and more uncomfortable.

    Eventually, relief is prescribed in the form of--an enema.  A human  conversation in the form of a doctor to doctor discussion of the patient's prior conditions and accommodations would have made his recovery from the surgery so much more comfortable.  Instead the inevitable discomfort of the surgery was made worse by adding more discomfort.

    My conclusion: medicine human to human connection as well as technology. I want my doctors to use technology effectively, but I also want them to listen to me and connect with me as a patient rather than as a disease.  I am very fortunate to have found a new doctor who has this combination, but I worry for all those who aren't getting that kind of care.  I'm also convinced that a human connection with doctors and nurses and other medical people helps us trust our care better and helps us follow through with our treatments.  It's not just warm and fuzzy stuff; it's part of our healing.

    Thanks to all. This is about 5% of the mail that has arrived on the topic. Will keep looking through it. 

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  • The Transformation of a Company Town: St. Marys, Part 1

    What happens when the company shuts down?

    Derelict former site of the Gilman Paper Company plant, in St. Marys, Georgia. (James Fallows)

    Last week I mentioned the very impressive "career technical" high school my wife and I had visited in Camden County, on the Georgia coast just north of Florida. Now, some of the background on why the changes in this area have been more striking to us than in many other places we have visited.

    The picture at the top of this post shows the ruins of the Gilman Paper Company, in the coastal Camden County town of St. Marys. "Ruins" is the only possible term. Back in the early 1970s, when a young Jimmy Carter was running for governor of Georgia, Gilman was a fearsome political force in the state and essentially the only employer for many miles around. "Gilman Paper Company is the only major Georgia industry south of Brunswick and east of Waycross," its manager said in a speech around that time. "It can safely be stated that not less than 75 percent of the economy of Camden County is directly dependent on Gilman Paper Company." The picture below, from a Harper's article about St. Marys in 1972, is the same site as in the shot above, when the mill was running full-tilt and employing most of the working-age people in town.

    Back at that same time, when I was just out of college and my soon-to-be wife had a year still to go, we were -- along with my sister and half a dozen other contemporaries -- part of a Ralph Nader team dispatched to write about pollution, tax evasion, economic peonage, and other aspects of company-town life in now-hyper-stylish Savannah and other paper-mill towns in Georgia. The result was this book.

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    St. Marys was the most bleakly Dickensian of the places we visited. The mill paid good wages, in exchange for all-encompassing political and social control. Its corporate attorney was also the State Representative, and was the county attorney too; the result in tax policy and environmental regulation was predictable. The mill's manager was the local Big Man. The company's owners -- the Gilman brothers of Manhattan -- lived an art-patron life far removed from the harshness of their family's company town. In the past few years, whenever I have gone to brutal, polluted, boss-run factory towns in remote China, I have thought back to St. Marys. It wasn't that long ago that China's current reality was tolerated in the U.S.

    Wyman Westberry, from The Washington Monthly.

    What happened next is too convoluted to attempt to explain here. In brief: a young millwright named Wyman Westberry, who had become disgusted by what we'd now consider China-scale despoliation of the local river and marshlands, drew press attention to what was happening in this little enclave. That's him at left, around the time we first met. He called me late one night, we went down to learn about his town, and we wrote about him in our report. Eventually 60 Minutes and national and statewide media got interested in St Marys. In the midst of the furor, the local Big Men put out a contract to have Westberry killed (the going rate was $50,000, but the would-be hit man decided to keep the money but not carry out the hit). The administration of new Governor Jimmy Carter began paying attention; and -- at the end of an Elmore Leonard-worthy tale -- Wyman Westberry ended up surviving, and much of the local establishment either ended up in prison or died before coming to trial.

    You can read the subsequent blow-by-blow -- and I actually hope you will -- in a Washington Monthly article I wrote ten years after all the drama*, or in a (subscribers-only) Harper's article by Harrison Wellford and Peter Schuck from 1972, or this more recent Forbes piece on the "Fall of the House of Gilman," or from our original The Water Lords book.  [*UPDATE The scanned PDF of this issue of the Washington Monthly, by Unz.org, is a little squirrelly in its layout. But when you come to what seems to be the end, on page 19, you can click the > button at the top of the page and it will take you to the rest of the story. Or, you can click on the Entire Issue button, which should do the trick too. I am biased, but I think it's a gripping tale. For a while it had a movie option, which is something can't say about a lot of things I've written.] 

    As I'll describe in future dispatches, Wyman Westberry has stayed in town, and become a formidable figure -- and in a very different role from mill wright at a paper mill. That's him, on the left, a few weeks ago with me near St. Marys in the Okefenokee Swamp.

    The city too is transformed. When we first visited, the pollution from the paper mill was so thick and caustic that, as in a scene from modern China, even the Spanish moss had been poisoned from the trees. Now the trees look like this.

    Back then, there was a perpetual layer of ash on cars and houses downwind of the mill. Now the historic part of St. Marys -- the part not subject to strip-mall sprawl near the Interstate and the Kings Bay naval base -- looks like this:

    And, downtown:

    And across what had once been a fouled and polluted marsh:

    All of this is set-up to the story we have looked at during our recent trip to St. Marys. What happens when the company at the heart of a Company Town shuts down? How different is the new "company town" life that has come with the area's dependance on a large Navy base? What does the resilience of a man like Wyman Westberry tell us more generally? And is there any chance that a place like this, with its impressive high school and its ambition to become America's next space port, can become a "talent magnet" like Greenville or Burlington?

    More in upcoming installments. Here is the route to St. Marys, in red -- with the last little jog to avoid a prohibited zone over the Navy base.

    And what the scenery on the way down looked like.

    More of the St. Marys saga, starting with the "spaceport," to come. 

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  • 'I Love Sioux Falls,' Word-Cloud Style

    What residents' words tell you about their town.

    John Tierney and Deborah Fallows

    Deb Fallows -- whose relevant ID for the moment is as a linguistics expert and a fellow-traveler and co-pilot on our American Futures journeys [plus, my beloved wife since we were 21 years old] -- has a new post up, on the role of descriptive word clouds about the cities we have visited.

    She starts with the wonderful town of Sioux Falls, South Dakota, shown in word-cloud form above and in a late-summer photo last year, below. 

    The cloud, which she prepared with John Tierney, is based on combing through the interviews and notes we collected while there. She also has a form for submitting characteristic words about other towns. I could possibly be biased, but I think it's very much worth checking out. 

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