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.
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.
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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.
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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.
"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.
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.
[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:
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.
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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.
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.