Archive for August, 2009

Health Care: the Reform Before the Reform

August 21, 2009

We’re hearing a bunch of different messages about what “health care reform” involves. Obama is now saying it means “health insurance reform,” which many of us have trouble with.  I have a very good auto insurance policy. It neither drives nor maintains my car.  But we all seem pretty clear that we want to cover everybody (or nearly everybody), and that we want to reduce the cost of both health care and health insurance. Whether these various goals are mutually compatible is a whole other question.

But there are things that we can perfectly well do before getting into the details of who is to be covered for what, and perhaps one of the most important is to solve the medical data problem.  Right now, your medical records are paper full of illegible doctor longhand, plus some transcribed and typed notes, plus X-ray films plus images from scans, EEGs, and EKGs.  Depending on your age and state of health, those records may fill a single folder, or, like Mr.Wired’s, be the thickness of the entire New York City phone directory. Furthermore, those records may be taking up space in the office of several different offices and facilities, because Doctor #3 wants to know what Doctors #1 and 2 found when they checked you out for hallux valgus, how they treated it, and whether the treatment worked, before she takes up where they left off. So she has had you send for all of the records from Doctors #1 and 2, and, when necessary, pay for the copying and shipping.  Copying, meaning the originals stay where they started out.  Most health care facilities have at least one room devoted entirely to record storage, sometimes a lot more.

Sometimes, not unreasonably, patients decide they want to keep a set of their own medical records.  This requires another set of copying fees, and another quantum of storage space.  In addition, it requires the patient to find someplace to store X-ray films (which are, essentially, photographic negatives with all their attendant storage problems, and furthermore are roughly four times the size of most paper documents and places to store them.)

BTW, in many other countries (Chile is the one I know best), the medical records are considered the property of the patient, who keeps his/her own set of copies and takes them from doctor to doctor as needed.  I don’t know whether the doctors in question make and store their own set of copies. Considering that doctors do retire, move away, and die, this approach has a lot to recommend it.  Indeed, these days, doctors move around a lot more than they used to, and tracking down one’s records after a few years can be really difficult.

So anyway, creating, maintaining, storing, and transmitting paper medical records is expensive.  Regardless of what happens with the more global aspects of health care reform this year, we could cut medical costs a lot by digitizing the records.  Many practitioners do that now.  My orthopedist puts my X-rays on his computer monitor, where he can zoom in on areas of particular interest and show me utterly cool and fascinating things about them.  He can also email them to anybody who wants them. But his software may or may not be compatible with that of my physical therapist.  That’s where the Reform Before the Reform comes in.
We not only need to digitize medical records, we need a standard system for doing so, so that this information can be readily transmitted to anybody with a bona fide need to see it.  We could, of course, just wait till Microsoft crams their version (which they are undoubtedly working on in some cellar in Seattle) down everybody’s throat.  And in the meantime, health care providers who have committed their resources to some other system will of course be out of luck.  VCR vs Beta, anybody?

Health care is more important than home movies.  It’s important enough for the government to play a role in deciding on a digitization standard.  Presumably the National Institutes of Health would be the place to start.  But obviously the real world of private medicine has to be involved as well.  AMA?  There may be some professional organization of medical IT specialists with contributions to make as well.  Ideally, the private side should be getting together to formulate its standard, which the NIH boffins can then examine for obvious and not-so-obvious glitches.  Mr. Wired suggests that unless the glitches are deal-breakers from the point of view of NIH, their critique should be kept out of the process, or a very minimal amount of tweaking done to produce a workable product.  That product, with recommendations from the private sector and NIH, should then be forwarded to the Surgeon General for his rubber stamp.  Probably the resulting system should be open code and licenseable to everybody who wants it. After a reasonable period of time (5 years or so), all government agencies that deal with individual medical records can legitimately require that they be digitized in the Standard Format, whatever it may be, and then, probably, everybody else will follow suit.

Within ten years, the system will have eliminated at least half the paper storage space (I’m assuming that the original originals will continue to be kept on paper, as a backup), and most of the costs of transmission and copying.  As an additional benefit, that digitized information can be made available almost instantly on demand for emergency responders.

Obviously, such highly personal records will need to be kept under varying levels of security.  One level for emergency responders, another for primary care providers, maybe another level for insurers, and so on.  Which is a lot easier to do (and where necessary, undo) digitally than on paper.  A person’s entire medical record could be kept on a single memory stick, and the emergency provider portion of it, probably, on a chip the size of the one embedded in my cat’s back to identify her if she goes astray.

No matter what else happens to the health care system over the next decade, this single advance can cut costs and improve care by significant amounts.  I don’t offhand know whether any other country has done this yet.  I know that various providers are doing it locally. The Veterans Administration is working on it.  But universality is more important here than anywhere else.  I welcome comments from the docs here, and anybody else with specialized knowledge to contribute.


Mirabile Dictu

August 20, 2009

(Which is Latin for:
Holy Cr*p)

Or maybe for “who’d a thunk it?”  I’ve been wondering for weeks where these utterly loony protestors at the health care reform town hall meetings are coming from, since they seem too loony to be mere garden-variety Republicans, and too organized to be mere “I’m mad as hell and not going to take it any more” individualists.  And now maybe we find out:  Lyndon LaRouche does it again!  We need to spread this before the health care reform is totally sabotaged.

Some background information:  Lyndon LaRouche – Wikipedia, the free encyclopedia is most of the public knowledge stuff.  The LaRouchies actually sort of got started here in Chicago, and used to have an office right down the hall from where the draft counseling agency I worked for in the early 1970s had ITS office.  What we noticed about them at the time was (a) they generated a huge amount of trash, which they rarely cleaned up, and (b) they spent a lot of time trashing leftist groups and activities.  At the time, that led a lot of us to suspect they were a CIA front.  Which in fact, like the Afghan mujahadin, they may actually have started out as, perhaps before going rogue.

But by 1986, they had gotten into the big time, at least in Illinois.  During the Democratic primary elections that year, when the regular Democrats were running Adlai Stevenson Jr. and George Sangmeister for governor and lieutenant-governor nominations, and Aurelia Pucinski for secretary of state, the LaRouchies ran Mark Fairchild for governor and Janice Hart for secretary of state, and won the primary.  Theories abounded about how it happened, but the most popular, and (I’m afraid) the most persuasive was that the voters found names like Fairchild and Hart more “American” than Sangmeister and Pucinski.  So Stevenson led a secession to a new party, the Solidarity Party, in the general election, and of course the Democrats got creamed by the largest numbers Illinois Republicans have polled in a very long time.

Given that kind of well-documented history, the LaRouchies’ current slash-and-burn techniques make perfectly good sense.  While some people still consider them to be leftist, or even some species of Democrats, they have from the very beginning done most of their damage TO the Left and the Democratic Party.  If they have any kind of ideology at all, it HAS to be right-wing.  Watch this space.

Red Emma

The Velvet Floor

August 18, 2009

or Benefit of Clout

Michael Vick’s rehabilitation pops up in the moral/religious blogs a lot these days.  It raises a lot of issues.  Like, who deserves a second chance? A second chance at what?  Is a professional athlete a role model, and if so, what are his obligations?  What about “morals clauses” in actors’ contracts?  What is forgiveness, and who is entitled to it?

I’m trying to dodge most of those questions right now, and deal with the one that gripes me most—the velvet floor.  That is, when ordinary people like you and me mess up, generally speaking, that’s the end of us.  If we get busted for felonies, we will do our time, and we will next be seen greeting customers at Wal-Mart or waiting tables at Denny’s, if not panhandling on the street or living in seedy Section 8 apartments on our Social Security benefits.

But when somebody rich or important gets busted, for just about anything short of first-degree murder, in the first place s/he is likely to do only minimal time in a reasonably decent institution. And upon getting out—well, junk bond fraudster Michael Milkin served his 22 months, and was then released to a halfway house where he was required to pay $1,300.00 per week for his room and board.  This was in 1993, when nobody I knew personally even earned $1,300.00 per week, much less lived anyplace where that was the cost of room and board.  And then there was Martha Stewart, who did 5 months in, and redecorated, a relatively decent women’s federal joint in West Virginia, and then returned to her $16M estate on Long Island to complete her sentence with house arrest.  Now she has paid her debt to society and is back running her enterprises and living the gracious life.  And now, Michael Vick is back on the street, reinstated in the NFL, and signed to a multi-million dollar contract.

OTOH, O.J. Simpson is in prison. Reportedly the institution is one of the newest and smallest in the state of Nevada, but he is in there for between 9 and 33 years, and, unlike Milkin, he is not in a position where he can talk his sentence down by giving information to the government, which already knows everything it wants to know about the original crime.

But that’s where Benefit of Clout comes in.  It’s analogous to Benefit of Clergy in the Middle Ages.  Remember?  That’s what Henry II and Becket fought over.  Becket won, though at serious cost to himself.  As a result, if you were a cleric (a status which, at that time, could range from archbishop to a merely literate male) and got busted for a first-time offense, your penalty was to lose your clerical status.  Kind of like Simpson lost his Public Image after being busted for the murder of his wife.  After the SECOND offense, you would be treated like any other criminal.  Like Simpson, in fact, after his hare-brained extortion, robbery, and kidnapping scheme.

Closer to home, my former alderman, who got busted a while back for taking a bribe, is now out of prison and making good money in real estate (or as good as anybody in real estate makes these days.)  I liked him; I felt bad when he went to prison.  But if I had done the same thing, I would probably still be behind bars. And when I got out, I would have nothing but my Social Security.

I’m not saying that Michael Vick SHOULDN’T have been reinstated in the NFL and signed by the Eagles.  Presumably he’s still a good football player, capable of doing the job he has been hired for.  His conviction was not for anything that impacts on his athletic performance.  Apparently he kept in shape while behind bars.  I’m just pointing out that the benefits of wealth and influence survive all kinds of public bad behavior, at least the first time around.  And maybe we need to think about whether they should.

Red Emma

More About Health Care, or Grist for the Ill

August 17, 2009

First of all, some senator, whose name now escapes me, says the “death panels” are a bad thing because doctors shouldn’t be doing end-of-life counseling anyway, that’s the job of Jesus Christ and your minister.  Well, aside from the fact that there ARE no “death panels,” and that many Americans are not Christian and therefore do not look to Jesus Christ for anything connected to the end of their lives, he actually has a point.  We SHOULD be making these decisions in conjunction with our imam, rabbi, high priestess, or pastor, if at all possible.  These guys may not know exactly what kind of life-extending treatment is available, but they certainly know their way through an ethical conundrum. That’s what they DO.  My father, of blessed memory, wrote a living will with the help of his pastor, who witnessed the document.  I relied on it during Dad’s final illness.  Despite the intrinsic sadness of the situation, I was enormously glad to have the document in front of me while dealing with the hospital.  Dad was, admittedly, much better than most people at advance planning in all areas of his life, which made life a whole lot easier for me and my brother.  But note that he didn’t ask his doctor about this stuff; he asked his pastor. And the pastor, relying on the “no heroic measures” language of the pre-Vatican II Catholic church, advised no resuscitation and no artificial ventilation, more than twenty years ago, long before it was a hot topic in political circles.

I think ALL religious organizations should be educating their clergy (and laity, for that matter) about their particular views on end-of-life care, and encouraging people to consult their clergy about these issues.  If they’re not good for that, whatthefrack ARE they good for?

Jane Grey

A Few Words About–Words

August 11, 2009

As a former English teacher and proofreader and a current lawyer, I get easily upset by abuse of the English language.  First there are the redundancies—you know, like “ATM machine,” “HIV virus,” and “PIN number.”  This summer’s biggies are “Latina woman” and the subject line of emails, which these days almost always reads: “Subject: re: whatever.”  “Re:” means “subject.”  (I think some people think it’s short for “regarding.” It isn’t. “Re” is Latin for “thing,” literally.)

Then there is the use of quotation marks as what one commentator has called the poor man’s boldface.  Now that everybody has boldface, can’t we just restrict quotes to their original purpose—indicating the reproduction of somebody else’s words?  Apparently that was part of the problem with Sarah Palin’s use of the phrases “death panel” and “level of productivity in society.”  The elitist literate few actually thought she was referring to something somebody else had said, and faulted her for not naming her source. In fact, she was just being snarky, which should have surprised nobody.

Again yesterday I heard the word “foreclosure” pronounced on NPR with the accent on the first syllable. Where on earth does that come from?

Have I missed some real bloopers?

Jane Grey

It All Started With the Witch Doctor

August 9, 2009

Since our Fearless Leader wants more stuff on health care, I’m contributing an abbreviated version of my first lecture in a course I occasionally teach, called “Professional Standards for Mental Health Workers.”  It has a heavily historical/anthropological slant, since my students, though highly competent and hard-working, generally have a lousy background in history, which I feel puts them at a serious disadvantage.

Let’s start with the premise that all professions are priesthoods, and all originate with healing the sick.  Terms like “witch doctor” and “medicine man” point clearly in this direction.”  “Medicine”, in Native American religious tradition is a synonym for “religious ritual/power.”  Like most pre-industrial medical traditions, it is based on the assumption that “sickness” can arise from or affect the body, the intellect, the emotions, and the spirit, in varying combinations.  Among the Navaho, for instance, many illnesses are believed to result from “sleeping with kinfolk,” contamination from proximity to corpses, or witchcraft–that is, the improper behavior of the patient or somebody else.

So the “medicine man” has to know things about the patient that the patient would  never want to become public knowledge. The patient will submit to treatment (and pay the doctor) only if the confidentiality of that information can be guaranteed.

Arthur C. Clarke, the science fiction writer, says that any technology we don’t understand is for all practical purposes magic. Healing the sick has always been one of the major attributes of divinities and their priests/shamans—a much more useful form of miracle than making water flow uphill or rods flower or whatever.  The ability to heal implies POWER, which is scary to those who lack it.  It implies, specifically, four kinds of power:
 power to heal
 power to withhold healing (“I don’t like you, or your brother killed my brother, so I won’t set your broken leg, nyah nyah nyah”)
 power to kill (anybody familiar with herbs knows poisons and abortifacients as   well as healing herbs)
 power derived from knowledge (about the natural world and about the patient–unavoidable access to confidential info) (imagine a delirious patient raving about a passionate interlude with a person to whom s/he is not married, for starters.)

So most cultures generate some kind of code for their priests and healers, to restrain this power and keep it channeled in paths likely to be useful for the culture as a whole. In this lecture, I assign the students to ask any professional or skilled craft person they meet during the week about the professional ethics of that craft, and get written documentation if possible.  I have gotten some fascinating samples: taxi drivers, sexual surrogates, veterinarians, child care workers, chefs—a long way from the Hippocratic Oath, which I generally see as the Ur-Document of its kind.  But they all have pretty much the same restrictions in common:
 Restrictions on use of knowledge and information
 first, do no harm:  for instance
 no poisons;
 in some cultures, no abortifacients
 no exposure of patients’ secrets (no blackmail)
 No favoritism in use of skills and knowledge, which must be made available to all, regardless of personality, affiliation, or resources
 No “overreaching”–using rare and necessary skills to extort undue recompense (pecuniary, or, for instance, sexual favors) (The course, naturally, has a whole lecture devoted exclusively to the issue of sex with patients/clients, which seems to be a problem for every profession with the possible exception of accountants, engineers, and veterinarians.  We’ve been blogging about Fountainhead lately, so you know it’s an issue for architects.)

The lecture then goes into a wildly condensed and popularized history of medicine, which I figure the various docs here are perfectly capable of providing us far beyond my poor amateurish power to add or detract.  The point of it, however, is not what technology and information has become available at various points in our history, but how we use it. Thus, it’s important to keep in mind that there is a big difference between:
(1) what we can conceive  of doing
(2) what we can actually do
(3) what we are  actually doing
(4) what most people actually have done.

These days we pretty much presume that we can develop any technology we decide we want to develop. The areas of cosmetic medicine, infertility treatment  and organ transplantation seem to be where we have actually decided we want to develop technology.  Economics is probably the driving force behind these choices.  Doing things people want is almost always more profitable than doing things people need.  It took medicine a while to come up with serious work in the former area, but now medical science has clearly taken that ball and run with it.  More about this later.
At the same time, mental health issues, which seem to be more and more salient as a source of real social problems, are being offered less and less attention from everybody except the drug companies.  This is probably economically driven too.  Drug companies can make lots of money in large gobs, while the more labor-intensive methods of treating mental illness dribble out the money in tiny drips to lots of people. .  The things psychotherapy can do–usually over long periods with close attention–are miles away from what most psychiatric patients actually get.
All of the chapters of the history of medicine exist in the US today, side by side, like the rings on a tree.  There is a ring in which sickness is still believed to result from the patient’s improper behavior (these days, we have given up on policing health in the bedroom, and taken up jackbooted thuggery in the dining room instead, but the results are the same.)  There is another ring in which the most drastic intervention is the most highly regarded (especially in the treatment  of cancer, where chemotherapy does a lot of the same thing that purges and bleeding used to do–the Ben Tre “destroy the village to save it” theory of medicine.)   There is a ring in which the doctor’s job is to keep the patient comfortable until nature takes its course (that’s what hospice care is all about.)  There is a ring in which medicine actually works, like a well-run car repair shop.  And finally, the local “wise woman” is still around (herbal shops and healers in Chinatown, Hispanic neighborhoods, and New Age enclaves, etc.)

The economics of medicine work differently in each of these rings.  Undoubtedly, whatever finally comes out of Congress (if anything) will not be fine-tuned to these distinctions.  Probably we should be looking for a minimalist and mostly-preventive approach: make sure everybody, regardless of ability to pay, gets vaccinations, wellness counseling, treatment for infectious diseases, mental health care, and palliative end-of-life care, and let the Almighty Free Market do everything else. Mental health care, BTW, should be required to include some treatment for whatever DSM-V calls the compulsion to scream and shout disruptively at public meetings.  Without it, our democracy cannot survive.