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.
Navy pilots fly a P-8A Poseidon during a mission to assist in search and rescue operations for MH370. (US Navy)
As the mystery about the fate and location of MH370 continues, and as theories come and go about what might have happened, here is a note from J. Mac McClellan, long-time editor of Flying magazine, about a phenomenon I've mentioned frequently. First-world commercial air travel has become so extremely safe that when something does go wrong, figuring it out can be a huge challenge -- which heightens the mystery and, for many people, the terror of these episodes, by making them seem so random. You're sitting there grumbling about the discomforts of modern flight -- and then, for no apparent reason, your plane is the one headed into the sea. McClellan writes:
As you probably know the FAA standard, and pretty much the global standard, for certifying critical components and systems is one in a billion probability of failure, or 10 to the minus 9th. The FAA calls this standard "improbable."
That means in a transport category airplane [JF note: this includes airliners] the certification standard for a failure, or combination of failures, that would prevent the airplane from successfully landing on a runway must be one in a billion flights. Not hours, flights.
I remember that when the 777 was introduced it was such a sales success and was expected to live such a long service life that some people speculated the fleet could actually make a billion flights. Of course, you don't need to make a billion flights to draw the magic short one-in-a-billion straw. But it is something to think about. Transport flying is now so safe that the long time standard of 10 to the minus 9th may not satisfy the public.
I'm sure you are also tired of hearing about all of the things a transponder does that it really can't. Every comment on a transponder says it reports course and speed, but we know a transponder, even a Mode S as you have and the 777 has, reports only an identification code and Mode C pressure altitude. Course and speed all must be calculated by observation by radar. I guess the media and experts have mixed up what ADS-B does with what a transponder does. [For more on transponders, here; on for ADS-B, here.]
Also odd that the 777 FBW [fly-by-wire, or electronic system for directing the airplane's control surfaces] system has escaped almost all speculation. It was the first for Boeing. And it was failure of the pitot input that put the FBW system into "direct law." [That is, it disabled the normal automated limits on "control inputs" the pilots could give to the airplane. In "normal law," which prevails within normal flight circumstances, the autopilot impedes or buffers any control input thought to be unsafe, for instance too sharp a turn or too steep a climb at too low an airspeed.] This handed the Air France crew an airplane that the computer could no longer control while expecting the humans to quickly diagnose a problem the computers couldn't. I'm not saying FBW has anything to do with 370 but it must be on the list of considerations.
This is not speculation, simply some basic info that I haven't seen touched on during the endless TV interviews and such.
The sobering point here is again that the very safety of modern air travel makes these episodes both intellectually and emotionally even more difficult.
One other aspect of the drama is the national reactions and tensions it has highlighted -- of course in Malaysia and China, also in Australia, even in Israel. Thanks to many people writing in with on-scene reports of reactions in China and Malaysia. Will sort them out and report as I can.
Walkways over the marshland, and beneath Spanish-moss-draped trees, to Camden County High School (James Fallows)
Earlier this month my wife and I spent about a week, in two visits, in the little town of St. Marys, Georgia, on the southernmost coast of Georgia just north of Florida and just east of the Okefenokee Swamp. It's a beautiful and historic town, which is best known either as the jumping-off point for visits to adjoining Cumberland Island National Seashore or for the enormous Kings Bay naval base, which is the East Coast home of U.S. Navy's nuclear-missile submarine fleet and which is the largest employer in the area.
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St. Marys is known to our family for its complicated and often-troubled corporate history, which I described long ago in a book called The Water Lords and which we'll return to in upcoming posts. But it also highlights an aspect of American education which we've encountered repeatedly in our travels around the country and is well illustrated by the school shown above, Camden County High School, or CCHS from this point on.
CCHS is the only high school in the county, drawing a total of some 2800 students from the cities of Kingsland (where it is located), St. Marys, and Woodbine plus unincorporated areas. Each year's graduating class is around 600 students. Its size gives it one advantage well-recognized in the area: it is a perennial athletic powerhouse and has won the state football championship three times in the past 10 years. It also has another advantage that I recognized from my own time as a student in a single-high-school community: it creates an enforced region-wide communal experience, across class and race, rather than the separation-by-suburb of many public schools. This part of Georgia has relatively few private or religious schools.
As a matter of statistics, the CCHS student body is more or less like the surrounding area: about one-quarter black, most of the rest white, and small numbers of other ethnic groups (including from Navy-related families). About 40% of the students qualify for reduced-price lunch, the main school proxy for income level, and about 60% go to post-high school training of any sort. Each year, a small number go away to out-of-state schools, including selective ones. In 2001, only 50.5% of the school's students graduated from high school. Now that is up to 85%, a change that Rachel Baldwin, the CCHS Career Instructional specialist who showed us around, attributed mainly to the school's application of programs from the Southern Regional Education Board. CCHS has the best AP record of high schools in its part of the state.
That's the background. Now what struck us, which was the very practical-minded and well-supported embrace of what used to be called "vocational education," and now is called the "career technical" approach.
In practice what this means is dividing a large, sprawling campus and student body into six "academies," with different emphases. One of them is the Freshman Academy, to get the new students acclimated. ("I don't know if you've seen ninth graders recently," one person there told us. "But some of them look big and old enough to be parents of some others. It's a big range, and it helps to have a special place for them.")
The other five academies each have a "career technical" emphasis. After freshman year, all students enroll in one of the five. While they still take the normal academic-core range of subjects, they also get extensive and seemingly very-well-equipped training in the realities of jobs they might hold.
A few examples:
- In the "law and justice" curriculum, which is part of the Government and Public Service Academy, a former Navy-Kings Bay NCIS official named Rich Gamble (right) trains students in conducting mock crime investigations, and preparation for testimony in court.
On the day we were there, he had staged a mock robbery, in which the perp grabbed a cashbox from an office, ran through the hallways, and dumped the box as he was escaping. (The students acting out the scenario wore their white CSI lab coats, so other teachers would know what they were up to.) Then Rich Gamble divided his students into three teams to investigate the crime -- making plaster casts of footprints (below), taking evidence, filing reports, preparing a case. "We emphasize a lot of writing," he said. "I give them issues where they have to defend themselves, in very few words, because courts don't like you to waste words. Some of these papers are as good as any written by NCIS."
In the Engineering and Industrial Technology Academy, students design and build doghouses and other structures, which they sell in the community; do welding (and compete in state and national welding competitions); run an auto-repair shop that handles county vehicles; do extensive electrical work, and other activities I'll suggest by the photos below. Wood-frame construction:
Inside the wood-and-electric shop:
This same academy also includes computer-aided design and robotics programs, under the direction of Fred Mercier. The houses in the first photo are ones his students had designed and built, sitting on top of a 3D printer they use. The contraption in the second is part of the school's entry in a national robotics competition.
3D printer above, catapult-throwing arm for robot (with Fred Mercier) below.
(These photos show young men, but that is happenstance of where it was feasible to take pictures. The academies are diversified by gender and race.)
In the Health and Environmental Sciences Academy, students were preparing for certification tests by administering care to dummies -- in this case, representing nursing-home patients.
There is more to show, including from the other two academies: Business and Marketing, and Fine Arts. CCHS has an industrial-scale kitchen and catering facility, overseen by a former Navy chef. It has a very large auditorium, where students not only perform plays, dances, and concerts but also learn to build scenery and make costumes. I'm running out of time, and you've got the point by now.
Here is why we found this interesting and surprising. Among the non-expert U.S. public, the conventional wisdom about today's education system is more or less this:
- At the highest levels, it's very good, though always endangered by budget cuts and other problems;
- At the lower ends, it's in chronic crisis, for budgetary and other reasons;
- And overall it's not doing as much as it should to prepare students for practical jobs skills, especially for the significant group who are not going to get four-year college degrees. Sure, the Germans are great at this, with their apprenticeship programs and all. But Americans never take "voc ed" seriously.
I'm not trying now to address all levels of this perception, and one high school doesn't prove a national trend. But what struck us at Camden County High was its resonance with developments we have seen elsewhere,: schooling explicitly intended to deal with the third issue, serious training for higher-value "technical" jobs. This is theme that John Tierney has previously discussed regarding schools in Maine and Vermont, and Deb Fallows about South Carolina. "Non-college" often serves as a catchall, covering everything from minimum-wage-or-worse food-service jobs, to highly skilled hands-on technical and engineering jobs that may be the next era's counterpart to the lost paradise of assembly-line jobs that paid a family-living wage in the Fifties and Sixties.
"In the past, we've encouraged all kids to go to college, because of the idea that it made the big difference in income levels," Rachel Baldwin told me on the phone this morning. She then mentioned a recent public radio series on the origins of success, and said: "The recent evidence suggests really goes back to something like 'grit.' I think you are more likely to learn grit in one of these technical classes. The plumber who has grit may turn out to be more entrepreneurial and successful than someone with an advanced degree. Our goal has been getting students a skill and a credential that puts them above just the entry-level job, including if they're using that to pay for college."
And oh, yes: What the weight room looks like for a state-champion football team.
Thanks to all at Camden County High. And Rachel Baldwin has written in with a closing thought on the career-technical/traditional-academic balance:
As a naval community, Camden County appreciates the phrase “a rising tide raises all ships.” Our AP students at CCHS thrive in Career Technical options (we have more than 20 AP course offerings), along with students who would be considered traditionally “vocational” in the past. Our administration and faculty, believing in "all ships rise," recognize and provide strong support for both achievement at higher academic levels and meeting the new technical demands of the workplace.
I mentioned last week that I was admiringly fascinated by wingsuit videos but could never imagine leaping off those cliffs myself.
In the video below, Sean "Stanley" Leary, a very well-known figure in the field, describes the exhilaration and freedom he has found in this pursuit. "The best part -- well, there's a lot of best parts, but the first best part..." he says late in this clip.
What he is describing sounds dangerous, and is. Earlier this month Sean Leary was killed, at age 38, during a wingsuit flight at Zion National Park in Utah. You can read more about his story here and here.
The video above is of course all the more poignant in light of how his deliberate embrace of risk ended. But it is also very eloquent, just on its own. For instance, compare Leary's description, during the first minute of this clip, of the "exit" or moment of leaping off and beginning flight, with what you see starting at time 1:40 in the well-known clip below.
Or with what you see starting at time 0:15 of this terrifying one, from Italy.
This is posted to close the loop after previous wingsuit mentions, and to note the outlook with which Leary and his colleagues approach these risks, and with great sympathies for his wife, who is now pregnant with their first child.
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Last month Deb Fallows did several popular posts -- here, here, and here -- about regional variations in the question you ask someone when you've first been introduced. "Where do you work?" "Who are your people?" "How long have you lived here?" and so on.
I mention it now for two reasons. One is to tout the wonderful video that Katherine Wells, of the Atlantic's video team, has made about answers to just this question. She phoned people from around the country and recorded their responses, building on leads from Deb's items. I find it haunting and will be surprised if you don't think it worth a look. The direct link is here, and it is embedded below.
This video also ends with a lovely presentation on the opening question that I have used when meeting people for as long as I can remember.
Reason two is to highlight another Esri map that John Tierney has made to illustrate a linguistic/sociological point. Earlier, Deb reported that a standard opening question in St. Louis was "Where did you go to high school?" John's map showed why the question had such resonance there.
In Greenville and surrounding upstate South Carolina, a standard opening question is "Where do you go to church?" This new map by John Tierney gives an idea why:
You can use the Plus and Minus keys to zoom in and out of the map; you can click on the Legend button to see how the color-coding matches the denomination, and you can click on any specific church to get more information about it. The background colors refer to the socio-economic "Tapestry" segmentation, so if you click on any neighborhood you'll get a popup about its social makeup. Of course there's at best a loose connection between neighborhood character and type/density of churches, since people don't necessarily attend services where they live. But the patterns are surprisingly interesting. (This is a Greenville-specific church map, as the school one was St. Louis-specific, because of the hand-coding involved on John Tierney's part.)
Now, a bonus third reason, which connects this to some previous posts. In my article on Greenville I mention that the surrounding county was the last one in the state, which itself was the last one in the union, to observe Martin Luther King's birthday as a holiday. Over the weekend I posted a note from Knox White, long-serving mayor of Greenville, saying that the city itself had voted for MLK long before the more-conservative county did. It turns out that there is an entire academic study of just this point. It is "Religious Interests in Community Conflict: The Case of Martin Luther King Jr Holiday in Greenville, South Carolina," by four scholars from Furman University in Greenville. It is interesting, especially about the complexities of class-based and race-based politics, and you can read it here. Thanks to John Tierney for recommending it.
In an item yesterday about the latest Bloomberg-in-China flap, I quoted a note I'd received late last year from someone inside the company:
Outsiders think the worst explanation for this controversy is that it's concerned about selling terminals within China. It's bigger than that. Really it's about continuing sales all around the world, if Bloomberg can't promise having the fastest inside info from China.
Just now this note arrived, in the same vein:
I don't work for Bloomberg. But I do work for a competitor.
The primary reason for the suppressing China investigating reporting is not about terminals. It is about DATA.
Bloomberg terminals are clunky and old, but what makes the terminals valuable is the timeliness of information and data that the terminal delivers.
The data part is the most important asset for financial professionals that use Bloomberg terminals.
Bloomberg is afraid of being shut out of access to economic indicators and statistics for China. Granted this information/data as of today is unreliable and sketchy, but as China is forced to become more transparent (i.e. globalization of the yuan as a currency) it is going to have to provide more transparency on economic/financial indicators and statistics.
Bloomberg pulling back is not primarily because of terminal sales, although this is important, but access to financial information.
For the record: I've asked for on-the-record responses from Bloomberg spokespeople or officials; the one person I have heard back from said that the company declined to comment. Also, check out this ChinaFile conversation on the topic.
No doubt I'm biased, but I thought our 39th president did a great job on the show last night—as did Colbert, in being mock-disrespectfully jokey right up to the limit of what is seemly with an 89-year-old former president, but not beyond.
What I really liked about this segment, apart from seeing Carter so relaxed and quick, was the glimpse it gave of the person with enough political instinct to have become president in the first place. For example, check out Carter's little deadpan retort in the time between 1:05 and 1:15 in this first part of the interview. Or approximately 1:45 through 2:15, in which Carter explains the circumstances in which he might stop being a Baptist and join the Catholic Church. (Pre-roll ads involved.)
[UPDATE: The embedded videos seem not to be loading. As far as we can tell, this is a problem on Comedy Central's end rather than ours. For the moment, here's the link to Part 1 of the Carter-Colbert interview.]
While you're at it, why not watch that whole clip, and this second installment of the interview too? It includes great riffs on Carter's home-building activity for Habitat for Humanity and whether the other X-Presidents consider him the odd man out. [Update: Here is the link to interview Part 2.]
Politicians still bearing the obligations of office, especially presidents, can be only so informal, before the "but let's be serious" part kicks in. Politicians on the rise are often trying a little too hard to show that they are hip. This is a rare instance of someone far enough past those days (though not past the sting of losing, as Carter mentions several times) to be at his relaxed best, and still in good enough mental shape to pull it off. This was an unexpectedly nice moment, by Carter also Team Colbert.
Our new issue has an interview with Dr. David Blumenthal, who was in charge of the Obama administration's effort to promote the use of electronic medical records (EMRs). We've had two previous rounds of responses from doctors, technologists, patients, and others, one and two.
Now another round.
1) It's generational. Previously I quoted Dr. Creed Wait, formerly of Texas and now of Nebraska. He enumerated the practical problems the EMR requirement created for him. A reply:
I read [those] gripes and wanted to weigh in as well.
I am a physician and have had the privilege of training and practicing in different places across the country. I specialize in sports medicine. My experience with EMR is greatly different from my fellow physician.
Some of his complaints are valid, but it seems as though many of his issues are related to his own inadequacies utilizing or adapting to technology. My observation has been that practitioners above the age of 40 in general have problems adapting their practice habits to new technology. People under 40 (myself included) are already familiar with computers and can adapt more readily. Another point to consider is that older physicians (as I assume my colleague is) will eventually retire, and current medical students and residents who will take their places already find the "paper and pen" method quaint, if not antiquated.
2) Is money the problem, or isn't it? Another rebuttal to Dr. Wait's report:
I wonder why he doesn't notice the self-contradiction in his complaint about the medical records mandate.
On the one hand, he complains that small practices like his don't have the big budgets that the VA and others use to make electronic medical records work well.
Then he complains about the $19B that the government has paid out to physicians for adopting electronic medical records, saying that if the systems worked well (like the cotton gin) no financial "carrots" would be necessary. But if lack of money to implement the systems is the problem, why isn't government funding to those using the systems precisely the right policy?
3) It's all about the software companies. From a doctor on the Gulf Coast of Florida:
I would parrot the statements of most of the physicians that you have quoted:
- EMR degrades the quality of information transfer in medical notes.
- EMR increases time of documentation.
- EMR costs more than our prior system.
I would also point out that transcriptionists are part of the disappearing middle class.
Who wins? EMR software companies…who I would point out market to CFOs, not physicians.
4) The driverless vehicle, a century before Google? From a non-physician:
- In 1985 I was teaching a group of state-level bureaucrats about our brand-new IBM System/36. One of the men sitting at the rear was a man with 30 years or so in the agency (USDA-ASCS), very assertive. Midway through the lesson (entering name and address data) he beckoned me over and said: "I don't type."
All of the complaints of the first doctor could be echoed in an assessment of our initial automation efforts. We basically automated what we were doing on paper, without rethinking what we did to use the hardware better. Took us years before we (the Washington bureaucrats and systems designers) learned better so our applications actually helped the county offices.
- I recommend this book to the doctor: Lakwete, Angela. Inventing the Cotton Gin: Machine and Myth in Antebellum America. The truth about the cotton gin is that it took a long time (i.e. 20 years or so) to work improve Whitney's gin and change the processing of the lint cotton downstream from the ginning to the point where it represented a great advance.
-Finally, I'm old enough to remember the transition from horses to tractor on our farm. Though the tractor then was a reliable machine, changing over was not a simple process--dad underestimated the time and cost.
So my point is the transition always takes longer than predicted, and usually is complex than the advocates of change concede. And there's always a trade-off. My mother could remember returning from Binghamton, NY after selling their farm produce, and letting the team find their way home--the driverless-car 100 years before Google.
5) "I'll choose a universal (electronic) record every time." From a reader in the Midwest.
I have some experience with EMRs—I’m a technology and healthcare writer and have written about them for many years for provider groups and insurers, and at one point, for an independent EMR lab that allowed small practices to experiment with various solutions before buying. I’m also a patient, of course, and my family here in [a major university city] sees clinicians within the University of [xx] Health System, which uses a very sophisticated EMR.
Your coverage of this issue has been fascinating. The criticisms of physicians from smaller independent practices do have an air of intransigence (we might call it whining), but many of the concerns are valid. The benefits of an EMR for a small, independent clinical practice are likely outweighed by the costs and complexity, certainly in the near term. But for larger practices and health systems, they’re indispensible. I can’t tell you how reassuring it is as a parent to know that any doctor or specialist we see has access to my daughter’s entire clinical history. If we have to run to the ER at 2am on a Saturday, god forbid, it is immensely comforting to know that the resident examining our child has exactly the same information as her primary care physician, and has a complete picture of her medical history since the day she was born. There is no scenario I can imagine in which the alternative leads to safer or more effective care.
But the physician who writes that “technological fixes only work in the context of appropriate institutional structures” is correct. The value we see in our local system as patients and parents is not really observed during a regular checkup or sick visit to the doctor’s office. It’s in having clinical information shared across every provider we come into contact with through the course of our lives. The minute we see a doctor outside the university system (if we go to an independent urgent care clinic, for example), those benefits begin to erode, and the larger story is a much harder sell.
But the market and regulatory regime do seem to be addressing this. The move toward accountable care organizations (ACOs) is very much an institutional framework under which EMRs make sense and begin to add tremendous value. ACOs are geared toward Medicare beneficiaries, but the consolidation happening in the larger industry is following the same path.
In many parts of the country, smaller practices can have their EMRs partially or entirely subsidized by the larger hospital systems with which they work. This makes sense on many levels. Hospital systems benefit by having a more consistent, universal medical record of the patients they see, while smaller practices and physician groups gain much lower barriers to adoption, as well as ongoing support and training superior to what they could sustain on their own. The downside is the loss of independence of the small practice. I can certainly see how, as small business owners, physicians might resist this change. But as a patient, I see the benefits to my family far outweighing the risks of that loss of independence.
Consolidation introduces its own challenges, and it’s not yet clear whether the financial incentive structures (especially in consolidation outside of ACOs) will counterbalance the higher prices that can result from fewer competitors in the marketplace. But in terms of quality and safety of the care provided, I’ll choose the larger provider group that’s embraced a universal medical record for my family every time.
6) A solution for staring at the computer. A reader in northern California writes:
Re: information systems in medicine, I am a Kaiser patient, and am intrigued by one small comment made by several people, that doctors must turn their backs on the patient to enter data into the computer.
No, at Kaiser, Northern California, they do not. The computer is on a roll-around stand, and the doctor or nurse is facing me while using it. Simple solution. Perhaps there are other simple solutions for some of the complaints.
7) Similarly positive experience in Seattle:
My primary care physician works out of a small non-profit clinic here. An EMR system has been in use there since soon after I my first visit about 5 years ago and my experience has been entirely positive. Examination rooms are arranged so the doctor doesn’t have to turn away from the patient while viewing the screen. Patient history is available at all three locations, to the doctor, nurse, assistant, and front desk. Other information, for example background for interpreting test results, is available promptly. There is a patient portal where doctor and patient can exchange messages such as test results. What’s not to like?
I have no knowledge of the system in use nor of the staff’s opinion. My doctor, nurses, and assistants have keyboarded info during a visit and it doesn’t seem to me to be too distracting. The experience described by previous correspondents on this issue is amazingly poor and I can imagine their dislike of those systems. I can’t imagine this small non-profit clinic spending a great deal on an EMR several years ago unless they expected immediate benefit. From my point of view they got it.
8) Finally for now, reliance on medical records as category error:
As an IT practitioner I have been following the slow-motion and entirely predictable train wreck of EMRs for some time now, starting with Microsoft HealthVault and the ill-fated Google Health in 2007.
A timeline, with some observations:
- March 2008: ars technica has a decent overview of the situation. The takeaway: "many of the reasons for poor US health outcomes have much deeper structural roots related to a lack of preventative care versus emergency care, issues that are tied in to the lack of a universal healthcare system and the nature of insurance companies, that are outside the scope of medical records databases".
- March 2010: The announcement of $20 billion in the stimulus bill for electronic health records (EHR) has started a gold rush. There's excellent coverage of the IT issues by Andy Oram on the O'Reilly Radar weblog. It elides the political question unfortunately - with single-payer many of the complexities of the IT implementations simply disappear. The problem of interoperability of competing systems vanishes, for one.
An IEEE Spectrum article covers some of the security implications. In particular my paranoia is confirmed by Dr. Deborah Peel, who writes
"Today our [the patient's] lab test results are disclosed to insurance companies before we even know the results. Prescriptions are data-mined by pharmacies, pharmaceutical technology vendors, hospitals and are sold to insurers, drug companies, employers and others willing to pay for the information."
EHR will only expedite this process. I'd like to see a blunt rule in the HIT regulations that gives ownership of the medical record to the patient and his heirs and assigns. Currently the ownership is vested somewhere in the aether.
- July 2010: the HIT has released its "meaningful use" criteria for the adoption of EHR by doctors, etc. This offers a few thousand dollars (from the stimulus package) for implementation of an EHR. As Andy Oram observes,
"The catch is that they can't just install the electronic system, but have to demonstrate that they're using it in ways that will improve patient care, reduce costs, allow different providers to securely share data, and provide data to government researchers in order to find better ways to care for patients. That's what "meaningful use" means."
A few thousand isn't going to do it. The costs of EHR fall upon the doctor, the benefits accrue to society and the patient. The costs are much higher than a couple of thousand, especially considering the current wholly dysfunctional state of EHR. Many EHRs have no API at all, others have incompatible ones, and so depressingly on. Single-payer with a single EHR solves all these problems at once, but because it's politically impossible, we're left with hideous technical problems.
Trying to solve US healthcare problems with EMR/EHRs is a category mistake, like trying to take the integral of a head of cabbage.. as your midwest doctor observed, " technological fixes only work in the context of appropriate institutional structures. "
A little while ago I put up an extended Q-and-A with Ben Richardson, the latest member of the Bloomberg news team who has resigned in protest of the company's approach to stories that might offend the leadership in China.
I hope you read it; its main payoff are Richardson's answers to the questions, and a timeline of how this story has evolved through the past four months.
But here is the central point: fundamental questions about Bloomberg's integrity as a news organization have been raised by its own employees over these past few months. Its responsible leaders have -- so far -- refused to say anything in detail (apart from "it's not true"), or to entertain on-the-record questions about these allegations. And one of the rare on-the-record comments, by its chairman, has seemed to confirm assumptions that Bloomberg has decided to place its journalistic operation second to its financial-terminal business.
On All Things Considered today, David Folkenflik said that ex-mayor Michael Bloomberg had told his staff that they should think of themselves as journalists first. Great! If so, how about saying that in public, and taking questions on it?
I think I know what Bloomberg's best reporters would make of an institution that refused to answer questions about its decisions and relied on the stonewall policy.
A graphic for "China's Red Nobility," from a 2012 investigative series on corruption among the country's leading families. (
Four months ago, TheNew York Times ran a big story contending that Bloomberg editors had quashed an investigative report about corruption among leaders in China. The Times story was clearly based on informed comment from people inside Bloomberg who were unhappy about the result. It said that higher-ups at Bloomberg were worried that the story would hurt the company's sales of financial terminals—the mainstay of its business—inside China, since the main purchasers would be directly or indirectly subject to government control.
Like the NYT and some other Western news organizations, Bloomberg was already "on probation" with the Chinese government, because of some very brave and probing official-corruption stories the previous year—including the one on "Red Nobility" that is the source of the graphic above.
As a reminder, here are the main story steps since then:
The FT did a similar report (here, but paywalled), also clearly based on inside-Bloomberg sources and also saying that Matthew Winkler, Bloomberg's editor-in-chief, had ordered the story killed, for fear of ramifications inside China.
Bloomberg denied the reports, in categorical but not specific terms. I.e., variations on: Of course we didn't bow to political pressure, and the story was just not ready yet.
Amanda Bennett, a long-time editor and reporter with experience in China (she was co-author of Sidney Rittenberg's book, The Man Who Stayed Behind), promptly resigned as head of Bloomberg's investigative unit. She did not explicitly address the controversy but made her feelings clear in her resignation statement. It said: "I am totally proud of the work of the Bloomberg Projects and Investigations team over the past five years.... I’m also most proud of the groundbreaking June 2012 story that the team led, that for the first time exposed the wealth of the relatives of China’s top leaders. I’m proud of the courage it took from top to bottom in Bloomberg to make that happen."
Michael Forsythe, the Bloomberg reporter who had worked for decades in China and was involved in these corruption-investigation stories, was quickly suspended by Bloomberg. He later joined the NYT staff.
Bloomberg continued to deny the allegation of knuckling-under but refused to address any specifics. The story that reportedly was underway has not yet appeared.
Soon after the flap broke, I received several calls from people inside Bloomberg, all of them insisting that I say nothing that could identify them, or even about the fact that we had talked. One was from a person who warned me that it would be a big mistake to put too much faith in what this person said were competitively motivated attacks by Bloomberg rivals. The other calls were from Bloomberg reporters or staffers, who said that the NYT and FT reports were essentially accurate. I wrote to the man who reportedly gave the spiking order, editor-in-chief Matthew Winkler, and did not hear back.
Then, last week, the chairman of Bloomberg L.P., Peter Grauer, seemed to confirm the original accounts by saying that it had been a mistake for Bloomberg ever to deviate from its business-oriented coverage.
All this is prelude to the latest news, which is Ben Richardson's resignation as a Bloomberg editor. Jim Romenesko had the story yesterday, followed by this from Edward Wong of the NYT, who also had the story about Michael Forsythe back in November.
After I saw the item on Romenesko, I wrote to Richardson asking if he would say more about the situation. He agreed. What follows are my emailed questions to him and his replies:
James Fallows: Four months ago, during the Mike Forsythe episode, Bloomberg officials contended that his stories just "weren't ready," and that the accounts in the NYT and elsewhere were misleading or incomplete. What was your understanding of the episode and whether the company's claims were correct?
Ben Richardson: I was one of the two editors on the story that was spiked last year, and one of three who helmed the 2012 stories on the hidden wealth of China's Communist Party leaders, so I have a pretty intimate knowledge of what happened. Unfortunately, I am bound by a confidentiality agreement that prevents me from disclosing the details. That said, much has already become a matter of public knowledge.
I felt the NYT and FT articles were a fair account. As often happens in news coverage, the stories painted the picture in stark black and white when in reality it was more nuanced. However, the contention that the story "wasn't ready" is risible: the only proof of readiness is publication. The real question is whether the story had any merit, and if it did, how could we get it to press?
That's a simple question. So if Bloomberg felt the story had no merit, then why has the company not explained its reasons? Four seasoned, veteran journalists (with help from many others on the periphery) laboured for months on this story. Were we all wrong? All of us deficient in news judgment?
JF: Amanda Bennett left the company at that same time. I know you can't speak for her, but should outsiders see her departure and yours as similar reactions to a trend in coverage?
BR: Amanda Bennett must speak for herself on this. The only comment I can make is that her departure coincided with the decision to spike the China wealth story and the effective dismantling of her Projects & Investigations team -- along with the sacking of a number of seasoned and award-winning journalists. At the same time, the company is shifting ever-more resources into the short, bullet-point end of the news spectrum. That trend isn't unique to Bloomberg and is undoubtedly sound business, but the overall direction is clear.
JF: What happened, now, in March, 2014 to persuade you to leave the company, versus the controversy in November, 2013?
BR: Time. Like most Bloomberg staff, I have a family to support, credit card bills, taxes and a mortgage to pay. I timed my departure to the company's annual bonus.
JF: Is the main change that is afoot here on the Chinese side, in decreased tolerance for any investigation into (especially) leading-family corruption issues? Or is it on the Western-press side, in decreased willingness to run these risks?
BR: It's hard to say. I'm not aware of any reporting of this nature up until Bloomberg and the New York Times stories of 2012, so there's little to gauge the government reaction against. Those stories were published against the backdrop of a power transition, the purge of Bo Xilai and incoming president XI Jinping staking his legitimacy on cleaning up graft. And on top of that, growing inequality and soaring home prices are stoking public resentment of corruption -- making the government even more sensitive.
As for the international press, there are many reasons for crimped ambitions. The first is that these stories are immensely expensive to execute. Even if a news organisation has the money, it may not have enough people with the right skills. And then it needs the will. I don't know whether it was bravado fueled by ignorance or true cold-steel nerves, but Bloomberg stood up to intense bullying by the Chinese government in 2012. Last week in Hong Kong, Chairman Peter Grauer made it clear that China is just too big a market to miss out on. The jury's still out on how most other big organisations would handle a similar situation.
JF: If you were in charge, how would big Western news organizations set this balance? To be more precise, Bloomberg is in a different situation from NYT or WSJ, in that its main business is not reporting but financial services. How should Bloomberg set this balance?
BR: I'll combine this with your next question, "What is the main thing you would like people without experience in China to know about your situation and decision?"
Bloomberg has to act with the interests of the majority of its employees at heart. The company provides a good living for thousands of people. The vast majority of its news is untainted by the kind of constraints you see in China. If that's the kind of news its clients want, give it to them. The world is full of news organisations that feed different parts of the spectrum -- including many trade and specialist publications that never write critical articles of any kind. I think the debate should now move beyond Bloomberg.
Business and political power are inextricably linked everywhere. That's especially so in China, where both are largely in the hands of a single, unelected political party that forbids the free flow of information and ideas and operates behind a veil of secrecy. Lack of transparency and accountability fuel rampant corruption, human rights abuses and environmental crimes. As China goes global, those values and practices are in danger of gaining currency elsewhere.
The question is a bigger one for society as a whole. What value do we place on investigative journalism? If the world's best-resourced news organisation leaves the field, who will fill the gap?
I'm grateful to Ben Richardson for his quick and forthcoming answers. This may be the time also to share something I received from a person inside Bloomberg at the time the news first broke, which is a useful complement to what Ben Richardson says. This Bloomberg employee said:
There is a bigger contradiction for the company than most people perceive. Outsiders think the worst explanation for this controversy is that it's concerned about selling terminals within China. It's bigger than that. Really it's about continuing sales all around the world, if Bloomberg can't promise having the fastest inside info from China.
Everyone knows that it's a company that exists on the terminals. But now that they have saturated the US market, all of the growth will come from areas with these deep contradictions between the company's financial-business interests and its journalistic aspirations.
Until very recently, the very fact that Bloomberg was not principally a journalistic company seemed to be its greatest strategic asset. It could use the stream from those financial terminals to bankroll ever-expanding coverage, while companies that were mainly or only in the troubled journalism biz kept cutting back.
From Citizen Kane onward (and beforehand), it's been obvious that these extra-journalistic business ties can complicate news coverage. It's time for someone with standing-to-speak for Bloomberg values—Winkler, Grauer, or the mayor himself—to address these concerns directly.
Thomas Bayes wondering whether a customer has said "I want four candles" or "I want fork handles" (
A Bayes Tutorial )
Three perspectives worth mentioning this morning.
1) Mysterious disappearances were once the norm. A reader who runs a tech firm writes:
It's interesting to remember that this sort of mysterious disappearance was completely normal until comparatively recently. I'm not sure, but I think theTitanic (1912) may have been the first shipping disaster that played out in the press in nearly real time. Before 1899, the first news of a ship lost at sea was likely to be no news at all.
2) Eponyms of logic, Occam and Bayes. Most people easily grasp (though often stray from) the logical concept known as Occam's razor. It's the idea that, other things being equal, the simpler explanation for an event is more likely to be true. For instance, early in the MH370 mystery, one popular conjecture was that something terrible had gone wrong that impaired the pilots' ability to control the plane. And another popular one was that those pilots had found a way to sneak up underneath another plane, hide in its "radar shadow," and then peel off undetectably and land at a secretly arranged rendezvous site in Pakistan or Iran. Knowing nothing else, by Occam's razor sheer complexity made the second far less likely to be true.
I find that people have more trouble with the concept of Bayesian statistics or probability, or simply the name, even though the simplest version of its implications makes common sense. That simplest version is the idea that probability estimates can be continually improved and refined if they are adjusted to reflect past experience or new evidence.
Thus the image at the top of the page (taken from here, as is the example that follows). Acoustically, the phrases "I want four candles" and "I want fork handles" are practically identical, and if you listened to a recording with no other info, it would be 50/50 which statement the speaker had in mind. But if you're hearing this in a candle store, the probability changes in one way -- having nothing to do with the actual sound -- and in a cutlery store it changes the other way. There's much more to the concept, but that is the main idea. [Mea culpa! I did not know about the "Two Ronnies" episode on Fork Handles, but now I do.]
My reason for bringing this up is to point toward an interesting short book I read last year, which is all about this history of Bayes's approach and its modern implications. (Plus, why it probably should have been named not for the English clergyman/mathematician Thomas Bayes but for the French mathematician Pierre Simon Laplace.) The book is The Theory That Would Not Die, by Sharon Bertsch McGrayne.
3) Clear thinking about MH370. Here are two examples. One is an article by Les Abend, a long-time 777 pilot whose sane-sounding judgments I have praised before. On the CNN site today he gives a chronology that discards some wild implausibilities and explains how a mechanical problem could have led to the evidence we now have.
The other is an update from Chris Goodfellow, who ten days ago offered the first plausible-seeming discussion of why mechanical/electrical error --rather than hijacking, terrorism, or suicide -- was the least-implausible explanation for what went wrong. His views got a churlish early dismissal from Slate and some TV pundits, but I think they have held up better than some other theories. Today he explains how the latest evidence affects his interpretation, and mentions the Les Abend post. (This is on Google+ rather than a normal blog so you may need to prowl around a little.)
The photo above is from the small South Carolina city of Greer, which is midway between Greenville and Spartanburg and whose downtown-revitalization efforts I mention briefly in my article in our current issue. I will be reporting on Greer soon, and I mention it now as segue to three updates:
Reinvention and resilience across the nation Read more
1) Are small towns "virtuous"? Not really. But they can be effective. Most of this article is about the specific ways in which some cities we've visited have addressed their civic problems, improved their economic prospects, and overall made themselves more attractive places to live. Those specifics matter, and as a relative newcomer to the thriving and crowded field of city-improvement studies (of which Atlantic Cities is an excellent chronicler), I've been fascinated by the ways in which successful tactics spread.
But there is a general point I consider increasingly important, so let me hammer it home once again. It's this, which contrasts our willed, structural paralysis in presidential-congressional politics which what is feasible elsewhere:
Once you look away from the national level, the American style of self-government can seem practical-minded, nonideological, future-oriented, and capable of compromise. These are of course the very traits we seem to have lost in our national politics.
The sappy version of appreciating smaller-town effectiveness is the idea that away from the metropolis, people are nicer, more generous, godlier, and so on. I don't buy it. People are people. Romanticizing small-town virtue is like imagining that the reason Western research centers produce so many Nobel prize winners, and Chinese ones so few (none), is that Americans are more "creative"—as these same Chinese researchers miraculously become when relocated from Tsinghua to Berkeley. The real explanation in these cases, I think, is institutional: incentives reward people for getting things done at a local level, and often for not doing so at the national level.
As another smaller-town mayor I quoted in the story, Don Ness of the (wonderful) town Duluth, Minnesota, put it:
“Being a mayor, especially in a ‘strong mayor’ city system, gives you tremendous opportunities... It’s a job that requires—and allows—you to create and implement a tangible agenda. You can carry that out in a way that most positions in American politics just don’t permit.”
That's true. And since we also need a functioning national government, it raises questions about how we could change the rules and incentives there.
2) Greenville City, Greenville County, and Martin Luther King. I mention in my article that Greenville County was the last one in South Carolina, which itself was the last state in the union, to observe Martin Luther King's birthday as a holiday. I also quoted this reader on its racist past—and since have heard from many current residents, black and white, about changes since then. The longtime mayor of Greenville, Knox White, who is one of the protagonists of my story, writes in with this clarification about the holiday:
I see that a former county council's public foot dragging on MLK came up. The City long, long ago declared a holiday and when the county council did not follow suit the perpetrators were all swept from office in the next election. Most were defeated in the GOP primary.
Indeed there are important political and demographic differences between the city of Greenville and surrounding Greenville County. Like most cities compared with their rural areas, the city is politically more liberal. For instance, Mitt Romney trounced Barack Obama county-wide in Greenville, but the race was very close within the city. I take the mayor's point.
3) Lake Monsters and Reds. My article points out that civic leaders in Greenville made a big push to build a downtown stadium for their minor-league baseball team, the Red Sox-affiliated Drive. (Named, it appears, for the local BMW and Michelin plants.) And Senator Bernie Sanders, in his days as a crusading mayor of Burlington, Vermont, made a big push to get a stadium for their minor-league team, which was then Cincinnati Reds-affiliated and was called the Vermont Reds. They have since left and are now known as the Akron Rubber Ducks.
As anyone who has been to Burlington knows, the team that plays there now is called the Vermont Lake Monsters—logo below. Through an in-house jumble, we said that the local team "is called" the Reds, rather than "was called," thus presenting the name of the team Sanders brought in as if they were still there under current mayor Miro Weinberger.
Sorry for the mix-up. Mayor Sanders cheered for the Reds-affiliate Vermont Reds; Mayor Weinberger, for the A's-affiliate Lake Monsters. Go team(s).
A pilot looks out onto the southern Indian Ocean while searching for flight MH370 this weekend. (Reuters)
Once again I am spending most of today in transit, and the doors of a (commercial) flight are about to close. So this is a placeholder note about today's announcement from the Malaysian prime minister about the fate of Malaysia Air flight 370.
The most urgent concerns about this flight are of course those of the families affected. Next come questions about this airline, this model of aircraft, the air-traffic-control and air-safety operations in this part of the world, and any other potential source of longer-term systematic problems.
And then there is the question about how our news media deal with the unknowable. The human fascination with the fate of this flight is understandable and natural. So far it has been a mystery with no obvious precedent in the world of modern air travel.
Structurally, these past few weeks have also reinforced an obvious point about 24-hour cable news. Its basic premise is that what is happening right now is more important and compelling than whatever may have been regularly programmed on some other channel—or in the other aspects of your life. Thus it is natural that CNN, in particular, has gone wall-to-wall with coverage even on days with no development resembling actual news. This is the war-style coverage that gave CNN its start, applied to a different situation.
In terms of the content of news-while-waiting-for-news, I've come to value the analysts, panelists, "experts," and others who display two traits:
* They have emphasized the unknowability of the entire situation, the contradictory nature of much "evidence," and the tentativeness of assumptions about what could and could not have happened with MH370.
* At the same time, they have helped the public separate the possible-but-unconfirmed from the FantasyLand-wild improbabilities. The clearest indication of this last category is the "radar shadow" hypothesis, which I'll link to later. Or a prominent official's straight-faced assertion that the plane might be headed to Israel on an attack mission.
Two of the panelists who consistently met this test were Les Abend, a former commercial pilot, and Miles O'Brien, a TV veteran and (Cirrus) pilot. There may have been others, but they were the ones I saw most consistently talking sense.
Now, on the general phenomenon of speculating about the improbable, I give you this note from several days ago from reader T.J. Radcliffe, a scientist. He writes:
Your observation "modern airlines are so extraordinarily safe that when something goes wrong, the full story is usually by definition unusual" is precisely why speculation ahead of the data is so utterly irresponsible in this case.
The famous dictum "when you hear hoof-beats, think horses no zebras" only works because horses are a single, fairly common source of hoof-beats in everyday life.
For any given effect, good Bayesians are bound to focus their speculations on things that are about as probable as the most common cause. But in the case of modern air disasters, due to the amazing gains in safety in recent decades, the most common cause is always wildly improbable, which means there are an almost infinite number of alternatives of equally low probability. So speculation is pointless, and the people who do it are being flagrantly non-Bayesian, which never ends well.
Speculation, like imagination generally, is not a particularly effective tool for deciding what is true. We can and do imagine impossible things (perpetual motion machines, political violence that actually achieves its purported end) and we fail to imagine things that actually exist (evolution by variation and natural selection, creative non-violence as a viable strategy for political change). The human imagination is many things, but as a tool for knowing it's about as good as a hammer for tightening bolts.
For low-probability events when very little data is available, our ugly tendency to fall back on our imagination comes to the fore on all sides, as it has in the past two weeks with MH370. While my heart goes out to the loved ones of the passengers, that some of them cannot imagine how difficult it is to find wreckage in mid-ocean does not justify their harassment of public officials, who are no-doubt struggling with feelings of inadequacy due to their own lack of understanding of the laws of probability.
There is a Kuhnian revolution going on right now in our understanding of the world in terms of probability distributions rather than mechanical, binary, cause and effect. It will take decades or centuries for this to percolate through society, but the foolishness of non-Bayesian speculators in the case of MH370 is one more example of how the old ways fail all of us in times of crisis and heartbreak.
One of them writes, "There is a very American tendency to look for technological fixes for significant problems. In general, technological fixes only work in the context of appropriate institutional structures."
Our new issue has an interview with Dr. David Blumenthal about why it has taken the medical system so long to adopt electronic record-keeping, and what it will mean when the switch occurs. (Blumenthal led the Obama administration's effort to encourage that change.) On Friday several technology experts and doctors weighed in with responses. Here are a few more.
1) "Give us a cotton gin." Creed Wait, a family-practice doctor in Nebraska does not like the mandated shift to electronic records, at all. [I've added his name, as he sent permission to use it. Also he has moved from Texas to Nebraska.] For now, I am sharing his detailed complaint in full, rather than interspersing comments or "Yes, but" queries:
The saying is, “Build a better mousetrap and the world will beat a path to your door. “
The saying is not, “Build a different mousetrap, pay out nineteen billion dollars in incentives to use the mousetrap, mandate its use by law and punish those who fail to adopt it. Then shove the world kicking and screaming against their will through your door.”
So far, doctors have been paid $19B in incentives to buy EMRs [Electronic Medical Record systems]. No one had to incentivize the cotton gin. It was simply a better product.
The current EMR system is a mess because the current EMR systems in use by the majority of physicians were written in the Rube Goldberg School of Software Design and work poorly. There is no ‘asymmetry of benefits’ as proposed by Dr. Blumenthal. Unless, of course, what he means by this is that only the software companies are benefitting from these federal mandates. Then, I would agree with him. Yes, the benefits are asymmetrical.
Build a better mousetrap and we will use it. DVDs came out and they were better than VHS tapes. Overnight the whole world invested in new electronics, we bought DVDs and we threw out our VHS tapes. There was no need for $19B in incentives because DVDs were simply a better product. Flat screen televisions came out and we stopped buying cathode ray tube televisions. Why? Because they were a better product. Laws mandating the use of DVDs and flat screen TVs, bonuses for using them and punishments for failing to do so, were not needed. The market chose the better products.
Mandated EMR adoption requires carrots and sticks consisting of massive incentives and concomitant penalties because the products that are available work so poorly and are so severely user-unfriendly.
Using the VA system, Kaiser, and Geisinger as examples of the successful use of EMRs is disingenuous. These are massive systems with massive budgets and massive around-the-clock onsite IT departments. The vast majority of physicians are not in these megalithic systems.
Most of us are in much smaller practices. We have IT departments but the salesmen and software engineers who sold us these magic beans are already down the road looking for the next unsuspecting rube and cannot be reached. Our IT departments are swimming upstream trying to implement and maintain software that they do not understand while mandated changes to this software are being released before we can get the last update debugged and working. The doctors are always screaming because the systems are down, we can’t work until the system is running and the IT guys have the harried and glazed look of caged prey.
For the federal government to mandate the use of EMRs by every physician out there just because it works at the VA would be like telling the entire world, “OK, we made it to the moon. Now it is your turn. Any country that has not put a man on the moon within the next five years will be bombed. Every country that complies with this mandate will get a check for $1B. For those countries who fail to comply with this mandate, shelling will begin at 1:00AM, five years from today.”
What the federal government can do with a bottomless supply of tax dollars cannot be used to reasonably mandate what happens in small offices constrained by budget limitations.
One year ago in private practice I could see eighteen patients per day. A transcriptionist typewrote my notes. These were typically three pages long, concise, complete and extremely useful. Then our group bought an EMR.
After one year I was seeing fourteen patients a day, my notes were twelve pages long, the vital signs alone required a half page and the notes bordered on being useless.
My reimbursement per visit had increased, my face-to-face time with the patient was shorter, I was doing a poorer job, patients were less satisfied, and I was completely frustrated by trying to build each note out of dozens of pages of drop down menus.
Before implementing an EMR I had approached each patient encounter with an attitude of, “What can we do today to improve your health, happiness and overall satisfaction with life?” The patient and I would have a meaningful conversation about the pertinent issues. Once an EMR was implemented, a subtle change began. It was so gradual that at first I did not even recognize the poison. But after a few months I realized that the visit had slowly evolved into, “Just a minute, we need to be sure that we have checked off every box on every screen and we need to be sure that a narrative of some sort has been entered into every required field.” Then there were realizations like, “Oh, look. If we add one more point to the Review of Systems then we can raise the billing code one notch. Hold that thought while I click, ‘wears glasses’ under the ROS field!”
Well, time’s up! The fields are all now completed and all goals have been met! Next!
The EMR had become the primary influence in the interview. The dynamic had changed. The patient and I were now both in the room to feed the hunger of the software.
Don’t even get me started on CPOE (computer-based physician order entry systems). Physicians used to write their orders and clerks would enter these data into the computer. Under the new mandates, the physician is now a data entry clerk. What’s next? Is each hospital CEO going to be required to spend two hours a day manning the switchboard? It is claimed that CPOE systems reduce errors. In the real world, this is nonsense. It is all in how one collects and reports the data. Data collectors refuse to attribute errors to the CPOE system. Rather than blame the software, the physician is blamed for not understanding how to use the system correctly. Just like with office-based EMRs we refuse to admit that the Emperor is naked. I have seen physicians get past mandatory stop points during system entries, when the correct input was not an option, by inputting obviously erroneous answers so that they could keep working. Then the physician would call the pharmacy and verbally correct the entry. There are dozens of ‘back door’ fixes of this nature that allow physicians to keep working when a CPOE system locks up or cannot meet the needs of a unique patient. In my own experience I estimate than a CPOE system adds 1-3 hours of work to each day.
I am not a typist, I never have been a typist and I never will be. I can dictate a beautiful note. A typist can then create an excellent document from that dictation. There is no reasonable excuse for the government to mandate an end to this system when no one has a better product. There is no reasonable excuse for the government to mandate that I will now be a typist.
Now, on to the VA system. They have a great and highly integrated information management system, with one glaring flaw. As long as the patient stays completely within that system, it works. As long as the patient never sees a physician outside of the VA, it works. As long as the patient never gets a test, x-ray or is hospitalized outside of the VA, it works. But the VA does not integrate well outside of their own system. By the time non-VA physicians and hospitals can get records, reports or anything of value out of the VA, the patient is generally dead or cured.
But this is exactly the problem that integrated EMR systems were touted to cure. If the best EMR in the nation has not yet solved this one simple problem, why is the entire concept being shoved down our collective throats?
So, you want to revolutionize data management in healthcare? The starting point is a product that works. Give us a DVD, a flat-screen television.
Give us a cotton gin.
2) The latest snake oil. More skepticism about the coming changes:
I've been a clinical psychologist for many years, and it's long been clear to me that few patients are likely to benefit from the adoption of expensive, labor-intensive technologies, which do, indeed, make it easier for managers and other third parties to do their jobs.
In recent years we've been seeing increasingly aggressive attempts by a variety of self-interested parties to insist that a certain change in how health care services are provided or paid for - a change which, coincidentally, would have salutary effect on their company's bottom line or their own career - is precisely the snake oil which is needed to "cure" the present system of its ills.
Rather than making changes which would, in fact, be most likely to result in "the greatest good for the greatest number," what we've been seeing - and are almost certainly going to continue to see - are changes which reflect the outcomes of intense behind-the-scenes political maneuverings among "stakeholders," each of whom is trying to make sure that, when all is said and done, he will be among the "winners."
3) What the VA's experience shows, and doesn't. From a doctor in the upper Midwest:
I'm a practicing physician with significant experience in the VA system and at an institution that recently adopted a new EMR. There are some significant qualifications about the potential of EMRs to improve care in the USA.
1) The precedents of the VA system and systems like Kaiser are a bit misleading. A very good criticism of EMRs generally being adopted in the USA is that they are fundamentally built on billing systems. This is an inevitable consequence of the fact that the incentives to introduce EMRs are driven by reimbursement. Systems designed to maximize patient information would be somewhat different.
The older, clunky but functional VA system is better in this respect than the modern EMR I use at my academic institution. Dr. Blumenthal and his colleagues are inadvertantly partially responsible for this situation because the legislation incentivizing use of EMRs had to be built around reimbursement incentives-penalties. In our fragmented system, I don't see that alternatives were available to Dr. Blumenthal and his colleagues but realism about the results is necessary.
2) EMRs should, as they do in the VA system, reduce costs by reducing duplication of tests and services. This occurs only, however, in the context of relatively large, integrated systems. I routinely waste money by ordering tests that may well have been performed previously by other physicians because I don't have access to patients' medical records. Big Data isn't big unless it can be aggregated and used broadly. There may well be considerable consolidation among health care providers in the near future but any market or semi-market based system like ours is an obstacle to consolidation because it encourages inefficient winner take all behavior.
3) An analogous point is that ostensibly data-driven changes in clinical practice will not emerge without someone or something to actually analyze the data and develop optimal care approaches. We need something like the British National Institute for Health and Clinical Excellence (NICE), probably on a more ambitious scale, to push appropriate reforms in clinical practice.
There is a very American tendency to look for technological fixes for significant problems. In general, however, technological fixes only work in the context of appropriate institutional structures.
4) The good, the bad, and the worse. From a reader in Jerusalem:
Good: I'm a long-time software engineer and was recently talking to my hematologist about computers and medicine. She was very grateful for the change. She remembered patients coming in to the ER that the staff recognized, but they'd have a terrible time looking for the medical records. Multiple staff searching through mounds of folders and not finding the right one. Previous diagnosis helps a lot in figuring out what to do in an emergency.
Bad: On the other hand, my GP spends more time facing the computer screen than his patient. Prescriptions come out of the computer via his laser printer, which cranks away all day. But all the Rx are in the system, anywhere I go.
American docs used to leave the room in the middle of the visit to look things up, rather than turn away from the patient. Bedside manner. Uh, deskside manner.
On the third hand: Hacking.
I have new respect for the complexity and difficulty of this change. More to come.
... as Samuel Johnson might have sayeth, if he had gotten a look at these things.
We've previously explored the wonders of wingsuit-flying in China and assorted sites in Europe (plus underwater). Now I give you Switzerland, via Epic TV* and our friends at AOPA:
And in case you missed the flying-and-diving video the first time around, here it is again.
Plus, for some terrifying/riveting wingsuit video. check out this.
I love flying airplanes but would never dare try one of these wingsuit stunts. I also never get tired of seeing them. They have a dream/nightmare quality that is immediately recognizable though hard to define.
* Tech note: Sometimes this video displays an annoying Epic TV banner announcement across its upper half through its whole duration. If that happens, try refreshing the page and viewing the video again. That seems to thwart it.
As mentioned this morning, in our new issue I have an interview with Dr. David Blumenthal about the paradox of modernization in the American health care system. We all know that everything about medicine is becoming technologized, in ways good and bad. On the good, see previous interview with Eric Lander about the genomic-knowledge revolution. On the bad, see Jonathan Rauch on the industrialized process of dying. But we also know that nearly every visit to a medical facility begins with the tedium of filling out forms by hand.
David Blumenthal was in charge of the Obama administration's effort to speed the adoption of electronic medical records, and in the interview he explains why that has been hard but will be worthwhile.
Now, responses from readers in the tech and medical worlds. First, from David Handelsman, of a health-related data company in North Carolina:
One of the things that Dr. Blumenthal didn’t include in his response was that the health care industry needs to continue to create a culture of evidence-based medicine, beyond the activities at those organizations that are further along the maturity curve regarding electronic health records and healthcare technology.
The reality is that much of healthcare is administered to patients based upon the practitioner’s experience (patients he or she has seen with similar conditions), the practitioner’s ability to accurately recall the appropriate care for the patient being seen and, where time has allowed, the opportunity to stay current on healthcare research and able to then apply that research correctly to the patient at hand.
While I have the utmost respect for health care practitioners, there’s an awful lot of room here for what I’ll call non-optimized care. The practitioner’s experience may be incomplete – he or she may not have seen a patient “like this patient”. They’re ability to recall the best care options for “this type of patient” may be unreliable given the vast numbers of patients in their care. They may be lagging behind in current research and recommendations because there isn’t enough time in the day, and if they are current, they may still have the same issue of recall regarding complex health decisions.
Evidence-based medicine aims to provide optimal recommendations regarding patient care. When electronic data is available, the patient’s current situation can be electronically compared to other similar patients AND their respective healthcare outcomes. At that point, a recommendation for care for “this patient”, whose profile is aligned with “all of those similar patients”, can be made based upon the recorded outcomes. Please note that this should be considered a recommendation – the responsibility for providing care ultimately falls on the practitioner, and not an algorithm, but that practitioner should always have the best information at hand to determine the best course of care.
From a retired MD:
There is a rub [among many, I suspect] as seen in our personal records from digitized offices.
To respond to insurance company demands for documentation of visits, physicians can simply cut and paste the previous visit data onto the current visit, making such changes as are necessary. Every visit looks remarkably complete!
The volume of material viewed makes finding anything new difficult. The record becomes a document for the insurance company, barely useful for physician's own use or physician to physician communication.
From the academy:
I'm a PhD student in statistics working on prediction and causal inference using health data. I'd like to comment on a quote from your (great) interview with David Blumenthal about the promise of Electronic Medical Records:
Dr. Blumenthal says: "This will move us into a field that is taking shape right now, that of analytics. It will help us take these data and turn them into diagnostic information—into recommendations a physician can give a patient or that patients can get directly, online."
He seemingly conflates 'diagnostic information' and '[treatment] recommendations'. But they actually pose fundamentally different problems from a statistical perspective, and I think EMRs will play a much more transformative role in diagnosis than treatment. This is because diagnoses live in the realm of pure prediction, while treatment decisions live in the realm of causal inference. EMR data will be observational. Using observational data for pure prediction is completely valid, but using it for causal inference is only valid under strong assumptions of no unobserved confounding.
A common fallacy of Big Data Hype is the assumption that gathering boatloads of observational data will enable us to solve problems that are fundamentally causal in nature. There will certainly be special situations where EMR data can reliably drive treatment decisions (and this will be a big deal!), but such cases will be the minority.
By contrast, statistical algorithms should be able to almost always make excellent, reliable predictions about what conditions a new patient is likely to have or acquire given her own health history and the health histories of millions of other patients. These predictions, which are probabilistic diagnoses in themselves, can also guide decisions about which diagnostic tests to perform on which patients.
From someone in the tech industry:
This question in particular interested me:
"JF: In the broadest sense, what difference will better information technology make in our lives and health?"
And this part of the answer:
"DB: This will move us into a field that is taking shape right now, that of analytics. It will help us take these data and turn them into diagnostic information—into recommendations a physician can give a patient or that patients can get directly, online."
That’s where the future lies, and of course people want the benefit of it right now. Before, there was no market to make this sort of analytic product. Now that we have a growing electronic infrastructure for health information, there is a surge of traditional capitalist interest in turning that information into valuable knowledge, and selling it back to patients and doctors. That will happen. But it could never have happened until we got the data into digital form.
To which I would add three things:
1. Put simply, the short-term benefit is efficiency (easier/cheaper management of data for existing processes). The long term benefit is effectiveness (making people healthier)
2. YCombinator (the #1 tech incubator, based in SV) yesterday put out their 'Request for Startups -- Breakthrough Technologies', which included a section on health, notably:
"We’re especially interested in preventative healthcare, as this is probably the highest-leverage way to improve health. Sensors and data are interesting in lots of different areas, but especially for healthcare."
So certainly corroborating the "surge of traditional capitalist interest in turning that information into valuable knowledge." More here:
3. I share YC's view that preventative care holds huge potential returns. In general, I see "Health Care" being too focused on the "care" (e.g. I can get an appointment with an expert at John Hopkins within a week; they have all the latest equipment; the hospital is a nice building). And not focused enough on "health" (e.g. sixty year olds being in good enough shape to enjoy traveling and grand children; young people not being taken out of the work pool for a lack of basic medicine). Using data for preventative care could be a key component to redressing this - of course, it could also exacerbate it...