Search the KHIT Blog

Friday, August 18, 2017

The "opioid epidemic" and the EHR

From The New Yorker (my new hardcopy arrived in the snailmail today):
"...the President pointed out, again, that once a person starts using drugs it is “awfully tough” to get him off, but suggested that the problem might be avoided by telling young people that drugs are “no good, really bad for you in every way.” His wife, Melania, sat beside him, as if to echo Nancy Reagan’s support of the “Just say no” campaign during her husband’s Administration. But that message seems particularly inappropriate, given the epidemiology of this drug crisis: the first person many addicts would have to say no to is a health-care provider…"

Certainly getting a ton of media coverage across the last year or so. I can't claim to have done any deep study here going to the prevalence and incidence trends of late with respect to opioid class Rx. But, particularly in light of the President's (typically) confused assertion above, I do worry about (ulterior motive?) "conflation" -- "the first person many addicts would have to say no to is a health care provider" -- i.e., illegal street drugs vs. inappropriately, overused nominally legit Rx. As I reported in 2015,

I've had my own issues with proper "pain management" Rx obstruction:
...Tramadol 50 mg. I have some bulging disks and pinched nerves ("cervical and lumbar spondylosis with myelopathy"), in part the upshot of too many years of getting the crap knocked out of me while pursuing my absurd decades-long full-court Hoop Dreams, (I have the attestational eyebrow suture scars, and torn meniscal and MCL vestiges), followed by too many recent years of too much sitting, reading, and blogging for hours and days on end.

I usually took one Tramadol a day, in the early morning upon arising (even though the scrip said 'one every 4-6 hours as needed'). On bad days, I'd drop a 2nd one mid-day. They helped. Materially.

Given that DEA recently "rescheduled" Tramadol, I can't help but wonder whether my young doc wants to keep his fingerprints off the Rx. I'd given him my entire longitudinal Hx from my Vegas Primary, dumped from the EHR. I fail to see the point of doing an expensive encounter with yet another physician -- one who doesn't know me, and who will have to redundantly (and expensively) read the chart, listen to (or blow off) my CC Subjective, and either bless or deny the simple Rx request...
My current Muir Primary writes me for Meloxicam. 1x/day.

Works acceptably (if not quite as well). It's a NSAID, not an opioid. I'm largely over my irascible Tramadol snit.

More from The New Yorker piece:
During the 2016 Presidential campaign, when Donald Trump was asked about the opioid crisis he often mentioned that he first learned about the severity of the situation in New Hampshire, which he visited several times ahead of that state’s primary. In 2014, after West Virginia, New Hampshire had the second-highest rate of death from opioid and heroin overdoses, at twenty-two out of every hundred thousand residents. (In 2015, there were more than thirty thousand such deaths nationwide, and the rate is projected to rise.)

As Trump heard more about addiction, he began speaking about it at rallies and, sometimes, in personal terms. Five days before the New Hampshire primary, at an event in Manchester, Trump talked about his older brother, Fred, who died in 1981, following a long battle with alcoholism. “He had everything,” Trump said. “I mean, the most handsome guy. And then he got hooked and there was nothing—and by the way, nothing you could do about it.” A woman sitting behind him nodded in agreement, as others in the room listened, rapt. Yet, as much as people empathized with Trump’s conclusion that he was, on an individual level, powerless in the face of his brother’s addiction, some of them voted for him because he also claimed, with increasingly sweeping rhetoric, that he, and perhaps only he, could “solve” the national crisis.

Last Tuesday, the President attended a “major briefing” on the epidemic with the Secretary of Health and Human Services, Tom Price, and other aides, at his golf club in Bedminster, New Jersey. They had with them a draft report that had been prepared by a special commission chaired by Governor Chris Christie, of New Jersey. The draft is rich in recommendations for channelling additional resources to the crisis. One is that naloxone, an anti-overdose drug known commercially as Narcan, be provided to first responders at a lower cost. Another would expand the definition of the kinds of in-patient facilities that are eligible for reimbursement under Medicaid, which the authors say is the quickest way to get help to a large number of people. In fact, the report demonstrates the crucial role that Medicaid plays in addressing the crisis, and the program’s still greater potential for combatting it. (The report also helps explain why Senator Mitch McConnell had a hard time getting colleagues from states hit hard by opioids to sign on to an Obamacare repeal that called for gutting Medicaid.)

Trump, however, gave no sign of rethinking his approach to funding these public-health initiatives. Instead, before he upended the briefing with his threat to consume North Korea with “fire and fury,” he had focussed his remarks on finger-pointing and punitive measures. The opioid crisis, he said, is the fault of the Mexicans and the Chinese, who allow drugs to be sent from their nations to ours. The metric that he offered for success in handling the problem domestically was the number of federal drug prosecutions brought and the average length of prison terms they produced. Both have dropped since 2011, which the President sees as evidence not of a bipartisan consensus on the need for sentencing reform but as proof of the laxity and the bad faith of members of the Obama Administration, who, he said, had “looked at this scourge, and they let it go by.”

Attorney General Jeff Sessions has already instructed federal prosecutors to pursue charges yielding the maximum possible prison terms, and revoked earlier guidelines designed to avoid harsh mandatory minimum sentences in cases involving nonviolent drug offenders. This promises to expand the practice of mass incarceration, with people cycling in and out of prison without receiving treatment, and further generations of children being exposed to disruption, broken families, and, potentially, their own susceptibility to what painkillers seem to offer.

At the briefing, the President pointed out, again, that once a person starts using drugs it is “awfully tough” to get him off, but suggested that the problem might be avoided by telling young people that drugs are “no good, really bad for you in every way.” His wife, Melania, sat beside him, as if to echo Nancy Reagan’s support of the “Just say no” campaign during her husband’s Administration. But that message seems particularly inappropriate, given the epidemiology of this drug crisis: the first person many addicts would have to say no to is a health-care provider…
"Marijuana is an extremely dangerous drug ... Good people don't smoke marijuana."
This ignorant cracker never fails to raise my BP. To him, potentially dangerous overmedication problems are likely simply seen as law enforcement problems. For which, perhaps for-profit private prisons might be of assistance.

apropos, I have some distant tangential scholarly history on this topic. From my 1998 graduate thesis (on coercive mass drug testing):
...our government “finds,” on the basis of myriad reports—derived principally from news stories and social science investigative methods of wildly variant quality—that the use of illicit drugs, particularly in the workplace, is a sufficiently adverse social and economic phenomenon to justify the coerced participation of millions of asymptomatic citizens as “donors” of bioassay specimens for chemical metabolite analysis to uncover the presence of forbidden psychoactive recreational toxins. Willing, even eager submission to non-cause drug testing is coming to be seen as the latest variant of the Loyalty Oath, with aspersions cast upon the motives and character of dissenters. Legions of survey researchers provide an endless outpouring of statistics purporting to demonstrate the alarming prevalence and horrific economic and epidemiological costs of drug abuse. Vendors of laboratory services assure us that their technologies are utterly reliable, that only the “guilty” need be concerned. It’s For Our Own Good, we are soothingly told.

Is any of this so? Are the enabling laws and policies ethical and wise, grounded in coherent history and viable scientific data? Are such measures critical to public health and safety? Are the analytical procedures and technologies truly effective, and fail-safe to the point of negating reasonable concerns over the possibility of false accusation? Can the nation’s laboratory infrastructure deal competently with the already huge and rapidly increasing sample workload? Is such a forcible deterrence strategy the only feasible option available to us for promoting the health and welfare of both individuals and society as a whole?

The questions are timely ones. A spate of expansive and harsh new drug testing legislative proposals is under consideration by the 105th Congress and state legislatures around the nation, and commercial vendors of analytical technologies are rushing to market patented (and, as such, potentially enormously lucrative) alternatives to the conventional urine and blood tests traditionally used in drug bioassay. There now exist methods that use hair and saliva samples, as well as a recently introduced “patch” that, when worn on the skin, ostensibly reveals the presence of illicit compounds. Also recently in the news were reports on the commercial availability of a $20 drug testing “smear kit” called DrugAlert™ that parents are being encouraged to use on their childrens’ clothing, furniture, and possessions if they suspect their kids of drug use. The kits are returned to the vendor for analysis, after which a “confidential” report of findings is mailed back to the parents.

How did we arrive at such a state of alarm? The path leading to proposals for a panoptic metabolite surveillance state is a perplexing one...
We have learned nothing.

Welcome to Trump's "Just Say No" v2.0.
Trump Declares National Opioid Emergency (August 12th)

President Trump declared the opioid crisis a "national emergency" on Thursday, after declining to do so during a press briefing two days prior.

An advisory panel had urged the president to declare an emergency in an interim report last week.

"The opioid crisis is an emergency, and I'm saying officially right now it is an emergency. It's a national emergency. We're going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis," he told USA Today and other reporters during a press briefing.

Asked whether Trump needed "emergency powers" to make such a declaration, the president responded, "We're going to draw it up and we're going to make it a national emergency. It is a serious problem, the likes of which we have never had."

Physicians, policy experts, and health consultants reacted positively to the news of the Trump administration's decision to declare the opioid epidemic a national emergency. But what the President does next will determine how successful his efforts are, they suggested…
No details thus far on what will comprise an actual constructive, effective action plan.

So, down in the eRx data tables of every doc's EHR documentation, can we expect DOJ subpoenas? Or, short of that, Big Brother HHS gumshoeing of eRx transactions via online PBM intermediaries such as SureScripts?

To the extent that the escalated opioid Rx abuse incidence represents an exigent "national emergency," we will not arrest and prosecute our way out of it.

Some People Still Need Opioids
The crackdown on pain medication prescribing is intended to help the addiction crisis—but it’s leaving chronic pain patients in untenable situations.

On July 26, Todd Graham, 56, a well-respected rehabilitation specialist in Mishawaka, Indiana, lost his life. Earlier that day, a woman complaining of chronic pain had come to Graham’s office in hope of receiving an opioid such as Percocet, Vicodin, or long-acting OxyContin. He reportedly told her that opioids were not an appropriate first-line treatment for long-term pain—a view now shared by professionals—and she, reportedly, accepted his opinion. Her husband, however, became irate. Later, he tracked down the doctor and shot him twice in the head.

This horrific story has been showcased to confirm that physicians who specialize in chronic pain confront real threats from patients or their loved ones, particularly regarding opioid prescriptions. But Graham’s death also draws attention to another fraught development: In the face of an ever-worsening opioid crisis, physicians concerned about fueling the epidemic are increasingly heeding warnings and feeling pressured to constrain prescribing in the name of public health. As they do so, abruptly ending treatment regimens on which many chronic pain patients have come to rely, they end up leaving some patients in agonizing pain or worse…
My gravely ill daughter would be in abject, unbearable misery but for the morphine and MScontin she takes daily.

A doctor’s murder over an opioid prescription leaves an Indiana city with no easy answers

MISHAWAKA, Ind. — Dr. Todd Graham wasn’t yet halfway through his workday at South Bend Orthopaedics when a new patient came into his office here complaining of chronic pain.
Heeding the many warnings of health officials, he told her opioids weren’t the appropriate treatment.

But she was accompanied by her husband, who insisted on a prescription. Graham held his ground. The husband grew irate. The argument escalated to the point that Graham pulled out his phone and started recording audio until the couple left.

Two hours later, the husband would return, armed.

Graham didn’t know that the shouting in his office wasn’t the end of the confrontation. It was frightening, he told his colleagues. But the incident two weeks ago wasn’t out of the ordinary — physicians here and across the country have grown increasingly accustomed to disputes over opioids. So Graham didn’t call the police. He didn’t file a report. He just kept seeing patients.

Many of his peers say they would’ve done the same thing. Many of them have.

Now, they’re not so sure.

That’s what they whispered to one another at the funeral five days later — the funeral for Dr. Graham…

As a tangential aside, I'm reminded of an Ann Neumann's obervation on a nexus involving law enforcement and pain mangement.
Pain management in a facility where drug use is rampant— and, indeed, a major cause of incarceration— is problematic. Doctors and nurses can find it hard to believe a patient who tells them he’s in pain. “A culture of suspicion emerged concerning the illicit drug trafficking of narcotics intended for pain relief,” the Palliative Medicine report states. The “macho” prison culture also prevented many in pain from admitting what they felt. But a larger issue, one difficult to measure, exists: “prison healthcare staff may believe that prisoners deserve their suffering.” In other words, pain is punishment. Staff members tend to default on the side of pain when prescribing narcotics to hospice patients. If anyone deserves to be in pain, the thinking goes, don’t thieves, murderers, drug users, rapists? In church parlance and even in broader society, the belief that pain makes us better people is commonplace. In prison, suffering is part of the centuries-old plan.

Neumann, Ann. The Good Death: An Exploration of Dying in America (p. 170). Beacon Press. Kindle Edition.

More to come...

Tuesday, August 15, 2017

If the dx is "bigotry," is "doxxing" the effective tx?

"doxxing," a.k.a. "doxing." "Outing" someone online, usually as a tactic of intimidation or revenge.

Been a crazy couple of weeks. The uproar over now-fired Google resume-padding "senior software engineer" James Damore after he posted his incoherent anti-diversity "#GoogleManifesto," the near-daily escalating juvie war-threatening insult-fest between President Trump and North Korea's Kim Jong Un, and then the horrific, lethally violent racist events in Charlottesville VA.

 My reaction on Facebook.

I'm a bit relieved to report that my daughter's exigent Saddle PE situation has stabilized.

Now comes rapidly spreading "doxxing." The most visible proponent in the wake of Charlottesville, on Twitter:

News item (one of many now popping up):
Charlottesville White Supremacists Begin to Lose Jobs, Web Hosting Platforms

The doxxing of white supremacists who rallied to protect a statue of a loser general continues, to their shock. In turn, some of them are beginning to see consequences.

Twitter account @YesYoureRacist has been circulating photos of rally attendees who boldly eschewed the tradition of wearing a hood when one gathers in a mob to express vile ideology. Viral screaming racist Peter Cvjetanovic has already been exposed and reportedly regrets that he is getting attention, but that’s about all he does regret.

The New York Post reports that another of his racist compatriots, Cole White, has been fired from his job working at a Berkeley restaurant called Top Dog…
Well, what's not to love here? Engage in bigoted assholery, suffer the consequences? Inclusive of public shaming and perhaps loss of your job or other punitive outcomes?

Above, the shouting young man (Peter Cvjetanovic) at the forefront was ID'd as a University of Nevada, Reno student, and promptly doxxed.

Again, is this a justifiable and effective pushback tx for publicly expressed bigotry? Anyone see any potential problems here? If you're photographed or A/V'd doing this ignorant stuff in public, there's certainly no libel issue in getting doxxed, right?

Well, as long as the outing is incontrovertibly accurate, 'eh?
BTW, in medical chart-speak, "dx"=diagnosis, "px"=procedure (e.g., surgery), "tx"=treatment (e.g., meds)
I rarely pass up an opportunity to mock public displays of political mendacity (particularly when it's armed), reflexively reaching for the Photoshop for some quick sport.

So, anyone know who these Densa Society Charlottesville Manly White Power Warriors are? Beyond public calls for what is distressingly akin to Vigilanteism, might digital tools such as Facebook's AI "deep learning" facial recognition technology pin them down for doxxing?

I should note that I have long been a vocal defender of peoples' "privacy." See my 2008 post Privacy and the 4th Amendment amid the "War on Terror." See also my 1998 graduate thesis opposing warrantless drug testing.

Stay tuned. What do you think?


apropos of my earlier post on the recently fired Google bro'grammer "engineer."
The 'March on Google' protest has been cancelled
The "March on Google" protest scheduled to take place in multiple cities across the US this weekend has been cancelled.

In a statement on its official website, organisers claimed they had received "credible" terrorist threats from what they described as "known Alt Left terrorist groups," and were cancelling the march due to concerns "for the safety of our citizen participants."

The protest was organised by conspiracy theorist and Trump supporter Jack Posobiec and others after Google engineer James Damore was fired for writing an internal memo that suggested biological differences between men and women might be responsible for the gender divide in the tech industry. News of the memo — and Damore's subsequent firing — caused a wave of criticism from many on the right, who accused Google of suppressing free speech.

In a video announcing the March on Google event, which was scheduled for Saturday, August 19, Posobiec said that "this assault on freedom of speech ... needs to be stopped." There were marches planned for New York, Washington D.C., Austin, Google's HQ in Mountain View, California, and other Google offices around the country...
This, in the wake of an earlier report on CNN: "The far right is planning 9 rallies nationwide this weekend alone."

Lordy. So, the otherwise Manly, gun-toting bigots are the "victims," afraid of a bunch of tie-dyed "alt-left" hippies?


(NOTE: I had to replace the full original Vice/HBO video. I now comes with an age verification requirement.)

Ugly. Wonder how many of these bigots have "ObamaCare?" Wonder how many have one of more family forebears who fought ACTUAL Nazis during WWII.

UPDATE: Yves Smith of Naked Capitalism has chimed in on this video and the broader issue.
"Race is a social concept, not a scientific one." - J. Craig Venter, PhD
So, back to my original question, should activist bigots like this Christopher Cantwell dude in the video be "doxxed?" Publish his address (replete with Google 'street views') and phone number, and his employer (if he has a job)? Similar info on his extended family?

How about this? A fair game pushback tactic?
Spreading tactical "disinfo" to play on the paranoia of these militants to help spread distrust in their ranks and mitigate or neutralize their effectiveness. That OK?


From Wired:

LAST SATURDAY, LOGAN Smith, the man behind the Twitter account @YesYoureRacist, began posting photos of alleged white supremacist protesters in Charlottesville, Virginia—and gained over 300,000 followers in a single weekend, some of whom helped him expose the identities of the protesters. One of the people Smith outed has since been fired from his job at a Berkeley, California, hot dog stand. Another, pictured screaming and holding a tiki torch, claims he's been misrepresented as an “angry racist.”

Another was disowned by his family. Another, Kyle Quinn, was more than 1,000 miles away from Charlottesville at the time of the protest—a case of mistaken identity that brought a wave of threats and accusations of racism so large that Quinn felt unsafe in his home. Still another was James Alex Fields, Junior, who murdered anti-racist protestor Heather Heyer.

To some, this all makes Smith an internet hero. To others, he’s just the vile, destructive left wing doxer du jour. (Smith did not respond to request for comment, though he has discussed the campaign on NPR.)

So who's got truth on their side? The internet has always been a swamp of ambiguity, especially where doxing is concerned. But as doxing continues to evolve as the preferred tactic of both far right and left wing internet factions, it’s important to take a hard look at what each side is trying to accomplish. While the two sides use different logic to justify their actions, the true result is the same and even cumulative—leading to an arms race of financially incentivized, shame-slinging vigilantes…
Who gets fired for being a “Nazi”? Depends on how expendable you are
Working-class white nationalists and supremacists are being outed and fired, but the professional class is safe

As white supremacists stormed Charlottesville with tiki torches alit, thousands of amateur and professional photographers documented the mob’s movements on social media and on news sites. Portraits of rally-goers trickled through the digital ether, and as public outrage grew, many attendees’ identities were outed by digital vigilantes. As a result, stories abound of rally attendees being fired from their workplaces for their white supremacist leanings: a cook at the Berkeley-based Top Dog (technically, he resigned), a San Francisco electrician, a cook at an Uno Pizzeria franchise in Vermont, and a welder from South Carolina among them.

There is something comforting about the outing and firing of Nazis: it draws a line between what kinds of politics are socially and morally acceptable, and which aren’t. That’s more than the president could do in his post-riot address. Yet if you study those who were fired for being white nationalists or flirting with Nazism, you might be apt to notice a pattern: Generally, those who suffered the loss of their jobs were working-class men, working service labor. Simultaneously, we must face the fact that there are those with Nazi sympathies in positions of relative greater power who are utterly secure in their career tracks. That is indeed troubling…

Internet shaming: When mob justice goes virtual

...Kyle Quinn, an assistant professor at the University of Arkansas, was enjoying a pleasant night out with his wife at Crystal Bridges Museum in Bentonville, Ark. "I saw some nice art exhibits with my wife, and we went to dinner up there and just had a lovely evening," he told Pogue.

Suddenly, there was an inkling that something was amiss. "A lot of frantic emails from the university, trying to reach me. And I thought that my weekend was about to be ruined."

While Quinn was at that museum in Arkansas, white supremacists were gathering in Charlottesville, Virginia -- and on the Internet, outraged onlookers misidentified Quinn as one of the participants.

Did he think there was a resemblance? "Not really. I understand, I've got a beard!" he laughed. "I understand that some people could see a resemblance there. But anyone that knows me knew right away that that's not me."

But people who didn't know Quinn decided that he had to be punished. He began receiving "really vulgar messages that you could never air. There were messages coming to my email, messages on my work phone. Things on Twitter, Instagram, Facebook as well."  The messages implied that he was a racist.

That was Kyle Quinn's introduction to a modern form of public humiliation known as Internet shaming, where online mobs descend upon one person in a wildly out-of-proportion attack.
Quinn felt his personal safety was threatened. "The most troubling thing to me and my wife, really, was, someone identified where we live, our home address. Any time you have an angry mob and someone says, 'Hey, this is where the guy lives,' that's a threat in my book…
Goes precisely to my reservations.

One of my female FB friends took issue after I posted the article:
And now that it's happening to white men, it's suddenly a problem worthy of major network news. Color me unimpressed. It's clear a lot of these New Amerikkkan Klansmen have NOT been mis-identified. Now, if the major networks have started calling out the people who have been making women's and POC's lives HELL with this bullcrap, I'm ready to listen--but this is clearly once again centering men and their Freeze Peach.
Okeee dokeee, then. Well, I'm a white male. I was not in Charlottesville (or at any other rally). So, am I nonetheless fair game for erroneous "doxxing?"

More to come...

Sunday, August 13, 2017

dx from Hell update: ICD-10 I26.92

On March 29th, my younger daughter got a crushing diagnosis of Stage IV metastatic pancreatic cancer (ICD-10 code C25.9). Our lives have been on constant high anxiety ever since.

After seven subsequent rounds of chemo (every other Wed - Fri), she had follow-up CT and MRI scans Thursday afternoon.

We'd not been back home from Kaiser long when her oncologist called.

The good news: no new mets evident, substantial size reduction in both her primary pancreatic tumor and her numerous liver mets.

The bad news: a large "Saddle PE." An aortic pulmonary embolism (blood clot).

Above, that Wikipedia image looks like it could have been one of the PACS images the hospitalist showed us in her chart in the ER, where her Onco Doc had advised us to go straight away. We got to the ER at 6 pm. Heparin IV immediately, more bloodwork, and vitals monitoring.

Another long night. They told her she'd have to be admitted for Obs, too dangerous for her to go home prior to subsequent eval monitoring.

She got to a room on the 4th floor MedSurg unit at midnight. I told my wife to go home (she had a 6:30 a.m. work conference call upcoming). I "slept" on the couch (Kaiser, to their credit, doesn't have "visiting hours." Family can stay around the clock). I'm feeling better today, but I was totally wiped on Friday.

Danielle was discharged mid-day Friday. Her BP, pulse, other vitals, and labs indicated it to be safe enough. Henceforth she adds self-administered 2x/day Lovenox subcutaneous abdominal injections to her meds regimen (it's a heparin cousin, a blood thinner). She's handling all of this with substantial grace and fortitude.
Danielle was on a (no doubt Zoloft-assisted) roll in the ER, crackin' wise with the nurses and the docs. Her standup-worthy gallows-humor snarkiness perplexed the young on-call female hospitalist who came into the pod and walked her through the dx and prognostic particulars. We were "like, yeah, we get it. We have deep shit. What're we gonna do? Be all morose all the time?"
Dodged a big bullet. The three primary adverse outcomes of a Saddle PE: [1] total aortic blood flow blockage, and you die, [2] clot stuff breaks loose, jams up your aortic heart valve, and you die, or [3] clot stuff breaks loose, makes it through to your brain, and you have a stroke. Those who've read my "One in Three" essay about Danielle's late older sister might recall that Sissy suffered a stroke mid-way through her cancer illness. Post-stroke reality is no fun, for the patient and caregivers alike.

Meanwhile, The Crazy is on Tilt all week. Will Mr. Locked & Loaded, Fire & Fury Donald Trump attack North Korea? Venezuela too, just for Grins? Will the #GoogleManifesto snowflake bro'grammer successfully sue his now former employer? What's next for the knuckle-dragging "Alt-Right" (whom Tone-deaf Trump refuses to specifically and unequivocally disavow) after the obscene lethal racist carnage in Charlottesville?

I really need all this idiotic background noise in my life right now.


As I've noted before, my world is "all Epic, all the time" anymore. I again closely watched the Epic EHR UX of all the clinicians while Danielle was in the ER and on the floor. Paper is not "better," not even close. See, e.g., my prior post "From EMRs to EMTALA: Dorothy J. McNoble, MD, JD."

More to come...

Tuesday, August 8, 2017

And the 2017 Darwin Award, Silicon Valley Category, goes to...

That didn't take long. Google promptly ID'd (James Damore) and fired him. Like, Hel-LO? This is Google! They know everything about all of us. I heard they hired Big Head on a 1099 via TaskRabbit to unearth Mr. Manifesto.

Recent reporting:
The key mistake at the base of the Google anti-diversity manifesto
Monica Torres,

UPDATE [9:40pm, 8/7/17]: Google has fired an employee who wrote an internal memo blasting the company’s diversity policies. Identified in press reports as engineer James Damore, the man confirmed his dismissal in an email to Bloomberg, saying he had been fired for “perpetuating gender stereotypes.” Google’s Chief Executive Officer Sundar Pichai told employees on Monday that parts of the anti-diversity memo “violate our Code of Conduct and cross the line by advancing harmful gender stereotypes in our workplace.” Pichai’s statement, however, made no mention of action against the employee.

A male Google software engineer’s internal memo about Google’s workplace diversity initiatives was made public this weekend, stirring a heated debate that has reverberated across Silicon Valley.

Titled “Google’s Ideological Echo Chamber,” the 10-page manifesto was first reported by Motherboard and fully obtained by Gizmodo.

In it, the unnamed engineer said he believes women are underrepresented in tech because “men and women biologically differ in many ways.” According to the author, these genetic differences include that women have a lower stress tolerance and want more work-life balance, while men are born with a higher drive for status.

He neglects to mention any of the proven research on systemic stereotypes that hold women in tech back.

The key mistake of the manifesto is the assumption that diversity initiatives make it so that companies are not hiring the “best” people. In reality, research shows that companies don’t hire the best people until they strip away biases…
From TechCrunch:
Google has fired the employee behind a controversial memo on gender diversity that went viral inside the company, as well across Silicon Valley and much of the world’s tech industry.

The author, who has been revealed to be Harvard PhD graduate James Damore, confirmed to Bloomberg that he has been terminated from his role as an engineer at Google for “perpetuating gender stereotypes.”...
Another site claims he does not have a doctorate:
James Damore is a former software engineer at Google who is known for writing the manifesto titled "Google's Ideological Echo Chamber."

In his youth, James was a Chess champion and was awarded the title of FIDE Master. He graduated from the Illinois Mathematics and Science Academy a residential public high school located in Aurora, Illinois in 2007. James attended the University of Illinois at Urbana-Champaign from 2007-2010, graduating with a Bachelor of Science in Molecular biology, Physics, and Chemistry. He was pursuing a Master's degree in Systems biology from Harvard, but did not complete his studies.


As a student, James was a research assistant at both Princeton and Harvard as well as a research scientist at the Massachusetts Institute of Technology. He was employed as a software engineer at Google from December 2013 to August 2017...
His "manifesto" certainly did not appear to me to comprise PhD level writing (or aggregate argument logic). UPDATE: Looks like he'd padded his resume, and has now revised his LinkedIn page.

The opportunistic Twitter nutcases are out in full fury.

I saw one hawking a "James Damore Defense Fund" crowdsourcing page. Yeah, right. Lotta rubes ripe for the fleecing, I'm sure. He's reportedly "exploring his legal options." And, maybe there will be some nuisance litigation make-this-go-away money to be had.

This wasn't even a close call, HR/Employment Law-wise. Hostile Work Environment 101.
Back when I was in the Meaningful Use program, I repeatedly took what I thought to be well-deserved iconoclastic shots at both my employer and the federal agency that funded the RECs. I was always scrupulous to do so on my own time, dime, and byline (and nonetheless fully aware of the risk). Anonymous "concern trolling" is pretty weak beer. If he did so on company time (he obviously used the Google intranet), that's termination right there, particularly in light of his topic.
BTW: some relevant hashtags, #GoogleManifesto, #GoogleMemo, "#GoogleGate... Enjoy.

Young Mr. now-Radioactive, I hear Uber is looking for a new CEO.
Alternatively, I see a role for him in the cast of the next season of Silicon Valley HBO.

Tangentially, in general, calling coders "software engineers" is pretty dubious, IMO. e.g., see my March 14th post.


Columnist Michelle Goldberg:
Damore wasn’t fired for harboring stereotyped views about women. He was fired for putting those views into a memo and disseminating it throughout the company in a way that calls his colleagues’ competence into question. Damore describes women as having more “[o]penness directed towards feelings and aesthetics rather than ideas.” Noting that women suffer, on average, more “neuroticism” than men, he suggests, “This may contribute to the higher levels of anxiety women report on Googlegeist and to the lower number of women in high stress jobs.” Damore has every right to believe this. He should have a right to express these beliefs outside work; there are countless online communities where men are welcome to discuss women’s inherent shortcomings at length. Whether Damore has a right to express his views about women internally, and then expect women to be willing to work with him, is another question.

PM NOTE: I've gone back and re-read the entire "manifesto." Being sprinkled with rational thoughts and actual random truths here and there (and contextually-wanting half-truths) does not suffice to make a coherent, linearly progressing, compelling case (I got a laugh out of his Charles Murray-esqe overlapping Bell Curves schtick. Seriously?).

Still reads to me like "The Snowflake Libertarian Brogrammer's Lament" gussied up with a bunch of "scientific citations" cupcake sprinkles.


Just in. This is good: 
I’m a woman in computer science. Let me ladysplain the Google memo to you.
Updated by Cynthia Lee
I’m a lecturer in computer science at Stanford. I’ve taught at least four different programming languages, including assembly. I’ve had a single-digit employee number in a startup. Yes, I’m a woman in tech.

I have known, worked for, and taught countless men who could have written the now-infamous Google “manifesto” — or who are on some level persuaded by it. Given these facts, I’d like to treat it — and them — with some degree of charity and try to explain why it generated so much outrage.

At the outset, it must be conceded that, despite what some of the commentary has implied, the manifesto is not an unhinged rant. Its quasi-professional tone is a big part of what makes it so beguiling (to some) and also so dangerous. Many defenders seem genuinely baffled that a document that works so hard to appear dispassionate and reasonable could provoke such an emotional response. (Of course, some see that apparent disconnect not as baffling, but as a reason to have contempt for women, who in their eyes are confirming the charge that they are more emotional and less quantitative in their thinking.)…

Nicely done. Read all of it.

At one point Damore asserts that Google Diversity Policy is "bad for business."

You were hired to write CODE, son, you're not the CEO, COO, or a Board member. Neither were you hired to write Community College undergrad Comparative Gender Studies 101 term papers for dispersal on the Google intranet on the company's dime.


The ugly, pseudoscientific history behind that sexist Google manifesto
Ex-Googler James Damore’s biologically deterministic manifesto is the latest in a long lineage of pseudoscience

If you haven’t read the full text of this leaked memo that now-fired Google software engineer James Damore sent around to his co-workers, here’s the Cliff’s Notes version: A pervasive “left” bias at Google has “created a politically correct monoculture that maintains its hold by shaming dissenters into silence,” Damore claims. He states his belief that the reason that the company doesn’t have “50% representation of women in tech and leadership” may be because of “biological differences.”

“The distribution of preferences and abilities of men and women differ in part due to biological causes and that these differences may explain why we don’t see equal representation of women in tech and leadership,” Damore writes. “We need to stop assuming that gender gaps imply sexism.”

Damore continues by suggesting that the reason that there are few women in “top leadership positions” may be because of biological reasons, namely, “men’s higher drive for status.” His recommendation is that they accept these biological differences and assign men and women to different roles: “Women on average look for more work-life balance while men have a higher drive for status on average,” Damore writes.

The reasons that these “facts” of his have been ignored, he writes, is because “We all have biases and use motivated reasoning to dismiss ideas that run counter to our internal values.” He suggests that “the Left tends to deny science concerning biological differences between people (e.g., IQ and sex differences).”

You might be keen to ask: are Damore’s claims entirely false? Damore is good with rhetoric — to the layperson, or to anyone who doesn’t follow cultural politics or scientific debates, his ideas unfold quite rationally…
Read all of it. Nice refutation. Then read, say, Section 703 of Title VII of the Civil Rights Act ("Unlawful Employment Practices").


Sundar Pichai’s email to Google staff:
Subject: Our words matter

This has been a very difficult few days. I wanted to provide an update on the memo that was circulated over this past week.

First, let me say that we strongly support the right of Googlers to express themselves, and much of what was in that memo is fair to debate, regardless of whether a vast majority of Googlers disagree with it. However, portions of the memo violate our Code of Conduct and cross the line by advancing harmful gender stereotypes in our workplace. Our job is to build great products for users that make a difference in their lives. To suggest a group of our colleagues have traits that make them less biologically suited to that work is offensive and not OK. It is contrary to our basic values and our Code of Conduct, which expects “each Googler to do their utmost to create a workplace culture that is free of harassment, intimidation, bias and unlawful discrimination.”

The memo has clearly impacted our co-workers, some of whom are hurting and feel judged based on their gender. Our co-workers shouldn’t have to worry that each time they open their mouths to speak in a meeting, they have to prove that they are not like the memo states, being “agreeable” rather than “assertive,” showing a “lower stress tolerance,” or being “neurotic.”

At the same time, there are co-workers who are questioning whether they can safely express their views in the workplace (especially those with a minority viewpoint). They too feel under threat, and that is also not OK. People must feel free to express dissent. So to be clear again, many points raised in the memo — such as the portions criticizing Google’s trainings, questioning the role of ideology in the workplace, and debating whether programs for women and underserved groups are sufficiently open to all — are important topics. The author had a right to express their views on those topics — we encourage an environment in which people can do this and it remains our policy to not take action against anyone for prompting these discussions.

The past few days have been very difficult for many at the company, and we need to find a way to debate issues on which we might disagree — while doing so in line with our Code of Conduct. I’d encourage each of you to make an effort over the coming days to reach out to those who might have different perspectives from your own. I will be doing the same.

I have been on work related travel in Africa and Europe the past couple of weeks and had just started my family vacation here this week. I have decided to return tomorrow as clearly there’s a lot more to discuss as a group — including how we create a more inclusive environment for all.

So please join me, along with members of the leadership team at a town hall on Thursday. Check your calendar soon for details.

— Sundar
An essay about sex differences between men and women is the latest flashpoint in Silicon Valley’s simmering culture war
Maya Kosoff

After being fired from Google for writing and disseminating a 10-page disquisition raising questions about the company’s efforts to increase gender diversity, software engineer James Damore has been embraced by conservatives, who are all too happy to claim a defector from Silicon Valley as the latest martyr in the country’s culture war. Within 24 hours of being fired, Damore was being hailed as a brave truth-teller in the pages of National Review, had a potential job offer from Julian Assange of WikiLeaks, and, on Tuesday, gave his first major interview to alt-right YouTube personality Stefan Molyneux.

In a sprawling, 45-minute interview with Molyneux, whose other videos include titles like “Why Feminists Hate Men: What They Won’t Tell You!”, Damore accused the tech industry of “groupthink” and shaming conservatives. “I went to a diversity program at Google, it was . . . not recorded, totally secretive,” he said. “I heard things that I definitely disagreed with in some of our programs. I had some discussions there, there was lots of just shaming and ‘No you can’t say that, that’s sexist’ and ‘You can’t do this.’” Damore revealed he’d written the memo on a 12-hour plane ride after feeling prompted to do so by other “isolated” Google employees “not in this groupthink,” who had supposedly felt so uncomfortable with Google’s so-called progressive bias that they had thought about leaving the company.

Silicon Valley, for all its ostensible liberalism, has always been tinged by a strong strain of libertarianism. And in the wake of Donald Trump’s election, some in tech have grown more comfortable pushing back on what they see as a stifling, even discriminatory approach to increasing diversity in a mostly white, overwhelmingly male industry…
YouTube CEO Susan Wojcicki’s Response to the Controversial Google Anti-Diversity Memo
Yesterday, after reading the news, my daughter asked me a question. “Mom, is it true that there are biological reasons why there are fewer women in tech and leadership?”

That question, whether it’s been asked outright, whispered quietly, or simply lingered in the back of someone’s mind, has weighed heavily on me throughout my career in technology. Though I’ve been lucky to work at a company where I’ve received a lot of support—from leaders like Larry Page, Sergey Brin, Eric Schmidt, and Jonathan Rosenberg to mentors like Bill Campbell—my experience in the tech industry has shown me just how pervasive that question is.

Time and again, I’ve faced the slights that come with that question. I’ve had my abilities and commitment to my job questioned. I’ve been left out of key industry events and social gatherings. I’ve had meetings with external leaders where they primarily addressed the more junior male colleagues. I’ve had my comments frequently interrupted and my ideas ignored until they were rephrased by men. No matter how often this all happened, it still hurt…

Some of those responding to the memo are trying to defend its authorship as an issue of free speech. As a company that has long supported free expression, Google obviously stands by the right that employees have to voice, publish or tweet their opinions. But while people may have a right to express their beliefs in public, that does not mean companies cannot take action when women are subjected to comments that perpetuate negative stereotypes about them based on their gender. Every day, companies take action against employees who make unlawful statements about co-workers, or create hostile work environments.

For instance, what if we replaced the word “women” in the memo with another group? What if the memo said that biological differences amongst Black, Hispanic, or LGBTQ employees explained their underrepresentation in tech and leadership roles?…

More to come...

Monday, August 7, 2017

Day 200

Also of note: it's Day 193 of the 90 the President said he needed for "Extreme Vetting" of Muslims to Keep Us Safe (Travel Ban Executive Order v1.0, Jan 27th).

From The New Yorker:


More to come...

Friday, August 4, 2017

KHIT topics

Mostly in no particular order above (and relatively limited sub-topical granularity), other than to note that this blog began with gumshoeing "EHRs" as "The REC Blog" shortly after I was re-hired by HealthInsight in 2010 to resume EHR support work (that I'd begun in 2005 under the precursor federal QIO "DOQ-IT" initiative (before getting laid off in 2007 as a result of 8SOW budget mismanagement above me). See also here, from another of my blogs at the time.
I can only legitimately lay claim to relative "SME" status (Subject Matter Expert) to a few of the foregoing areas: e.g., EHRs (outpatient), Workflow, Process QI, Analytics, HIPAA, and, of course, Patient. For the remainder, I am simply a fairly well-read, endlessly curious student (ongoing) and activist citizen/reporter, and I take care here to cite (typically at some length) the best thinkers I encounter. I should be getting residuals from Amazon for all of the books I've touted and linked.
This blog started principally as an online "diary" of my experience of the Meaningful Use initiative within which I served as a workflow and HIPAA security consultant to small to medium primary care practices ("Project Coordinater" was my official title).

My incoming hope (naive, as it would turn out) was that we might leverage the REC opportunity to help practices materially improve their operations broadly (with perhaps collaborative involvement from my ASQ Health Care Division), with InfoTech at the center of that effort (after all, Medicare "QIOs" had been re-named to be "Quality Improvement Organizations," succeeding their prior designation as "PROs" -- Peer Review Organizations).

My REC, like all of them, quickly became simply "body count" focused -- getting MU client practices from EHR adoption to Stage I MU "attestation." We got paid incrementally through ONC via "milestone" achievements, and, being significantly understaffed to meet our practice recruitment and MU progress targets, "milestone compliance" it would be. Noble devotion to process QI would be seriously backburnered. Early on, I took some annoying crap from one of my Utah HQ Sups for even pushing the idea ("...exceeding your scope").

Whatever. I didn't make any secret of my reaction to that.

Given that the blog was my nights and weekends personal sidebar project, I began to broaden my scope to whatever I thought relevant to health care QI, always episodically rotating back around to Health IT. Hence the roaming span now comprising the effort. I've never entertained the idea of trying to "monetize" it. Now nominally "retired," I continue to write here simply because it's important, and maybe my little ankle-biting, no-ulterior-motives solo effort will add a bit of signal to the noise. I am grateful for all of you who stop by and read this stuff. I will try to keep showing up at the major Health IT and QI conferences. Next up, the Health 2.0 11th Annual Conference in Santa Clara.

Given my younger daughter's grave illness, it's been difficult to keep up with focus and pace lately. But, I will try to soldier on. As I post this today, she completes round 7 of her indeterminate length course of chemo. New CT and MRI scans on tap for next week. Imagine our anxiety.

Armed with science (and snark), a gynecologist takes on Trump, Goop, and all manner of bizarre health trends'

he tweets while she’s walking Luna, her nearly blind cat. (Yes, walking her. On a leash.) And while she’s at home, waiting for the sourdough to rise. She blogs while she’s directing her two teenage sons to fold the laundry.

In posts that careen between empathy, outrage, and snark, Dr. Jennifer Gunter presses a provocative crusade to protect women’s health, preserve reproductive freedoms — and, while she’s at it, dismantle all the dubious, dangerous medical advice she comes across in the wilds of the internet…

Stay tuned. See their antecedent paper "Why do humans reason?" (pdf) apropos of topics in cognitive neuroscience as they go to AI/NLP.

More to come...

Monday, July 31, 2017

From EMRs to EMTALA: Dorothy J. McNoble, MD, JD

Among my daily web surfing stops is the blog "Naked Capitalism," an always very busy, provocative, multi-contributor site established by acclaimed writer Yves Smith, whose book "Econned" is one of my favorites.

The focus at Naked Capitalism goes mostly to "FIRE Sector" (Finance, Insurance, & Real Estate) topics and issues. I resonate with this stuff owing in part to my intense 2000 - 2005 period working in risk management in Subprime. See, e.g., my old posts 'Tranche Warfare" and "The Dukes of Moral Hazard."

Well, last week Naked Capitalism published two delightful posts by Dorothy J. McNoble MD, JD going to the health care space -- specifically a national policy topic and a post concerning the shortcomings of Health IT (EHRs specifically).

The first one discusses the EMTALA (Emergency Medical Treatment and Active Labor Act of 1986).
Healthcare Hypocrisy: How Politicians Hide Behind the 1986 EMTALA Law to Avoid Healthcare Reform
Dorothy J. McNoble, MD, JD

A 46 year old man comes to the hospital by ambulance for severe abdominal pain. He is diagnosed with a perforated ulcer and undergoes emergency surgery. He receives post-operative fluids, antibiotics, pain medication and ulcer medication. He recovers after five days and is discharged. He is unemployed, has no insurance and neither the hospitals nor the physicians receive any payment for his care.

This story of timely and appropriate emergency medical care delivered to patients unable to pay for it occurs tens of thousands of times a day in this country. Though physicians and hospital administrators might provide such services for moral or ethical reasons, it is unnecessary to rely upon the consciences of these providers since a law mandates that they provide care.

Specifically, The Emergency Medical Treatment and Active Labor Act (EMTALA), passed by Congress in 1986 unequivocally requires that hospitals provide emergency medical and surgical care and other ancillary services to patients requesting this care irrespective of their ability to pay.

This law, though rarely mentioned by name during discussions of existing and proposed health care policy or law, has a profound and pervasive impact on the delivery of health care in this country. In fact, there is no area of government or privately provided health care which is not affected by the provisions of EMTALA and by the current economic sequela of this law.

In particular, many of the provisions of the Affordable Care Act were designed to remove some of the burdens imposed by the EMTALA. If the ACA is repealed, the benefits and burdens of EMTALA will emerge as more important than ever. It’s therefore important to make an explicit examination of EMTALA. Medicare, Medicaid, the Affordable Care Act and even rules governing private insurance cannot be fully understand without acknowledging the existence of this long standing health care safety net.

The Origins of EMTALA
EMTALA was passed in 1986 and requires that patients needing emergency medical care not be discharged or transferred to another hospital until the patient has received a medical screening exam. If the patient is found to have a condition requiring urgent medical or surgical care, that patient must receive the care unless he or she consents to discharge or transfer to another facility. The patient must receive this care without regard to his insurance status or his ability to pay for the care.

The law is an unfunded mandate. That is, unlike Medicaid, Medicare and the Affordable Care Act which establish taxpayer subsidy for the health care provided, EMTALA mandates the delivery of care, but contains no provision for funding the care. The law, as will be discussed below, has been interpreted very broadly and, as a result, it has a significant financial impact on health care in this country.

Uncompensated care represents up to an estimated 6% of total hospital costs. This number does not include the costs borne by the physicians and other providers as opposed to the institutional hospital costs, so the 6% is an underestimate of the cost. The hospitals in urban and rural areas with large numbers of medically indigent patients assume a much greater proportion of this cost and since the law is silent on funding and contains no provisions for reimbursement, there is no mechanism for spreading the cost among hospitals in a region in order to better distribute the loss…

…the EMTALA mandate has evolved to require a fairly expansive definition of emergency care, and, it is therefore remains a very costly proposition, especially for inner city and poor rural hospitals. It is impossible to know what would happen if the EMTALA mandate disappeared tomorrow, but I can predict with confidence that there would be a significant decrease in the amount of unreimbursed care provided by hospitals.

Finally, as the debate on health care reform continues, one should consider whether EMTALA may actually be responsible for allowing politicians and lawmakers to skirt responsibility for coming up with reasonable legislation to fund health care, especially care for the medically indigent.

As long as EMTALA is in place, patients will continue to receive all emergency care and even a great deal of arguably non-emergency care. Patients with strokes, diverticulitis, broken bones and even fingernail infections will be seen and treated irrespective of financial status and without regard to the existence or absence of any program for funding that care. This uncoupling of guaranteed care from payment for that care shields lawmakers from the consequences which would follow if hospitals and providers could turn away uninsured and indigent patients.

EMTALA is, in fact, a “forme frust” of single payer healthcare for the indigent. That is EMTALA requires a broad and deep level of care be provided for all patients, but has no mechanism for private or public funding of that service.

Instead, in our bastardized single player plan, the costs of the care are borne exclusively by the doctors and hospitals providing the care with no attempt to provide a sensible risk spreading plan for the multi-billion dollar EMTALA program.

President Trump and Secretary Price have stated their commitment to reduce this type of cost-shifting in health care. For example, they support the elimination of individual and employer mandates would end the program whereby healthy individuals are required to buy insurance to subsidize the sicker patients.

If the current Administration is serious about elimination unfair cost shifting, it seems that elimination of EMTALA, which is one of the most unfair cost-shifting systems in health care, should also be eliminated. If it is unfair to require healthy patients to purchase insurance to fund the sicker patients, then surely it is unfair to require individual physicians and hospitals to bear the burden of care for the medically indigent.

However, if EMTALA were to be eliminated, and hospitals and physicians responded by eschewing any responsibility for providing uncompensated care, politicians would arguably be faced with the prospect of dealing with a citizenry awash in illness, disease and suffering. I think that lawmakers recognize that EMTALA stands between them and health care chaos, and, in spite of platitudes about a fair distribution of the costs of health care they, will never have the courage to repeal this unfair law and replace it with an honest, universally accessible system of health care.
Link in the title. These are fairly long-read posts. Highly recommend you read them in full, inclusive of the numerous comments beneath the articles. Naked Capitalism attracts an astute, eloquent readership of varied (and predominantly well-reasoned) opinions.

The second McNoble post goes to to the by now long-standing complaints about EHRs.
How Electronic Health Records Degrade Care and Endanger Patients

Yves here. We’ve featured posts from the Health Care Renewal site that regularly warn about how electronic health care records are a serious hazard to patient health. Yet we’ve regularly had readers refuse to believe that, despite warnings like the ECRI Institute putting health care information technology as its top risk in its 2014 Patient Safety Concerns for Large Health Care Organizations report, or the president of the Citizen’s Council for Health Freedom warning that “EHRs are endangering your life” or press reports like this:

Arthur Allen at POLITICO Pro eHealth says government-imposed EHRs are:

  • Driving doctors to distraction
  • Igniting nurse protests
  • Crushing hospitals under debt
“In short,” he writes, “the current generation of electronic health records has about as many fans in medicine as Barack Obama at a tea party convention.“

Some readers assume that anything must be better than hand-written and potentially difficult-to-read doctor notes. And the 50,000 foot explanation, that the systems are a huge and costly fail from a care perspective because they are designed primarily, if not entirely, for billing, seems insufficient.

This post will hopefully satisfy the skeptics by giving granular detail with real-world examples of how these electronic record systems distract doctors, regularly employ dangerous “check the box” approaches, produce voluminous and repetitive patient files that routinely go unread, give nurses contradictory instructions, and too often result in patients being given “care” that harms them.

One of my friends, the daughter of an MD who worked for the NIH and later a Big Pharma co, said she’d never go to a hospital without her own private duty nurse. That was before EHRs. Once you read this article, you’ll think twice about going to a hospital in the US without that sort of extra protection.

By Dorothy J. McNoble, MD, JD, who can be reached at

In a now iconic experiment, subjects are asked to sit in bleachers watching a basketball practice and count the passes among players on one of the teams. A few minutes into the experiment a man in a gorilla costume walks across the court. Fewer than 50% of the subjects notice him.

In a variant of the experiment, a man stops a stranger on a somewhat busy street to ask directions. While they are talking, two men carrying a large piece of plywood walk between the two men and when the plywood has passed, the original questioner has been switched to a different man. Again fewer than 50% of people notice the change.

Recently, I witnessed an “invisible gorilla” episode in the hospital. I took my neighbor to the hospital after she had fainted. She had low blood pressure and a slow pulse. The nurse examined and interviewed her, but spent most of the interview facing the computer and inputting data. A few minutes later, my friend was moved two beds down and exchanged places with another patient due to some equipment problems. When the nurse returned to check on my friend, she addressed her by the incorrect name and questioned her about the symptoms of the patient who had been there earlier. I corrected her and she checked the armband to confirm.

There can be no denying that emergency rooms are busy and the staff are often overwhelmed, but I think this demonstrates that the new “three way” which dominates patient interactions – the patient, the computer and the nurse or doctor, risks turning patients from the central focus of all interactions into the invisible gorilla.

Anyone who has tried to wade through their own hospital records or watched as a primary care physician tried to decipher the “data dump” which is supposed to summarize the events of a recent hospitalization, will recognize that the promise of the efficient, orderly modern electronic record is far from being realized. In theory, the computer based electronic record should be perfectly suited to its task. In recent decades health care, especially inpatient hospitalization, has become increasingly complex. There are many more participants, doctors, nurses, dieticians, consultants, occupational therapists, respiratory therapists, social workers and the interventions and therapies and medications administered during a hospitalization have also increased dramatically.

The electronic record, with its ability to prompt clinicians with reminders, organize large amounts of data and allow access from any point in the hospital and even remote locations, seems the perfect tool to create an organized, complete, flexible document free of errors and redundancy. The EHR as a working document during the hospitalization should be able to immediately reflect changes in the patient’s condition, accommodate instantaneous changes in medication and therapy, allow input from a host of clinicians and remain clear and comprehensible. After the patient discharge, the EHR should be an easy to understand narrative of the event of the patient’s hospitalization with the patient as the obvious central figure.

However, instead, the EHR has become an unreadable, unholy mess in which the patient is increasingly eclipsed. How did this happen? Was it due to limitations of software capacity? Insufficient funds devoted to the development of the EHR?

All of these problems undoubtedly contribute to the difficulty of developing the optimal EHR system. However, I believe that the main impediment to the creation a good EHR is not technical limitations or financial constraint. Rather it is due to the decision to utilize the EHR as a billing document. Many of the decisions about how to organize the medical record, how to format the document, and what data to include or exclude arise from the need to use the record as the support for and documentation of “billable events” during the hospital stay...


Feeding at the Trough
Healthcare is the largest single industry in the country and the source of the greatest job growth. However, the growth in clinical care positions are not responsible for most of this increase. Medical and nursing schools have at most a negligible increase in graduates, and ancillary clinical training, such as occupational therapists is also growing slowly.

A large part of the increase in participants in the healthcare industry is due to the dramatic increase in federal, state, and local health care bureaucrats as well as the increases in hospital administrators, auditors, plan administrators and other non-clinical participants. These government and administrative bureaucracies are theoretically in place to insure efficiency in the delivery of care and to monitor and insure patient safety. The security of their roles as integral to patient care is assured if they can require that their particular area of concern is a mandated part of the medical record. For example, there must now be documentation in the EHR about smoking cessation, potential for elder abuse, vaccination status, use of seat belts use of child safety seats and a variety of other issues. Although the inclusion of these global safety and care concerns is laudable, the medical record has become bloated with repetitive, inappropriately placed mandatory documentation of these often peripheral and distracting subjects...

Focus Fatigue and Limited Bandwidth
As discussed above, the structure of the EHR is designed to serve its purpose as a billing document, but makes it very challenging as a dynamic health care management tool during hospitalization or a concise, complete, well organized, non- redundant narrative after discharge. These structural features are a real impediment to clinicians trying to care for patients or understand what happened to patients after the fact.

There is an ample body of literature discussing the inefficiency and inaccuracy which results from multi-tasking. When doctors and nurses attempt to examine and obtain histories from patients while scrolling between various lists on the computer screen to be certain that all the billable bases are covered, it is clear that their ability to attend to the patient is compromised.

In addition, when the record itself is lengthy, repetitive and contains large amounts of prominently placed, but extraneous information, the clinician is likely to lack the mental stamina to wade through the document, switching between screens to find the relevant information. Moreover, the much touted “safety” features of the EHR are themselves often so ubiquitous and distracting that they lose their efficacy...
Again, this post is a thorough long-read, one airing the broad litany of complaints that those of us who have worked in Health IT are utterly familiar with. And, also again, I recommend you read the numerous comments. Notwithstanding the usual naysaying straw man and related red herring grips are many views that deserve our attention and respect. e.g.,

I retired in 2010 at age 69, after 44 years of practice. The final 3 years involved EHRs at both a large multi-specialty clinic and at a teaching hospital, though the clinic and hospital systems were mutually incompatible. The clinic system was particularly clunky, despite frequent upgrades that required relearning the system. The deal-breaker, as far as I was concerned, was that the complexity of the system and tsunami of drop-down boxes (see Dr. McNoble’s superb discussion above) which required me to face the computer and interact with it, while having an over-the-shoulder discussion with the patient. This was anathema to me. My decades-long practice style had been face-to-face positioning with maximum eye contact and body language that said, “You have my full attention.” How could any patient possibly trust me otherwise?

My response to this situation probably fell under the rubric of ‘civil disobedience’. I abandoned any attempt at real-time data entry and continued my career-long face-to-face style, scribbling brief paper notes as the encounter progressed. Between patients (or more likely at the end of the day) I would rush back to my office and do the computer data entry. Obviously everything took twice as long as before. (That’s an exaggeration. A factor of 1.4 to 1.5 is probably more realistic.) Obviously, my productivity plummeted. To their credit, the MBAs who had assumed the power positions in the organization let me be, though they could not have been happy with what I was doing.

Probably I got by with slow-walking the transition only because I was the senior member of the group and everyone knew the checkered flag could be seen from my windshield. Younger physicians and mid-level practitioners who tried that would probably have been tossed out on their respective ears.

This is not intended to be a diatribe against electronic health records in general. Nor is the word ‘data’ the plural of the word ‘anecdote’. I don’t claim that EHRs cannot work, only that I was unable to make them work. In spite of being reasonably tech-savvy for an old goat. Would that I could offer a quick and easy solution for this nettlesome situation, which has been so well documented by Yves, Dr. Noble, and multiple eloquent commenters. Or any solution. Sorry, I can’t. Perhaps someone much smarter than me can.

“In theory, there is no difference between theory and practice. In practice, there is.” Yogi Berra

Kudos to you, Yves, to Dr. McNoble and to NC’s unsurpassed commentariat.

apropos, recall my earlier post "Are structured data the enemy of health care quality?"
Also of relevance, "Clinical workflow, clinical cognition, and the Distracted Mind."

I'd like to have Dr. Jerome Carter's (EHR Science) take on this second McNoble post.
My own hands-on EHR experience has become increasingly dated. My personal Meaningful Use client caseload extended to 14 different EHR platforms -- all of them ambulatory systems (whereas Dr. McNoble's lament dwells on the inpatient environment, a significantly different, far more complex beast).

As far as UX goes, I can just personally observe that my experience the past few years (now simply as a patient and now again as a caregiver) has been pretty much "all Epic all the time" (with the exception of my radiation oncologist). I'm a patient in the John Muir system. Epic EHR. I had my prostate cancer 2nd opinion at Stanford Medical Center. Epic. My daughter is now a Kaiser cancer patient. Epic. She was evaluated for clinical trials at UCSF Medical Center. Epic. When I'm at these encounters, I always watch the clinicians' EHR interactions carefully. I think a lot of the complaints about EHRs are hyperbolic. The UX I repeatedly witness is thoroughly trained-up, fast, and efficient. None of which is to argue that it couldn't be better. QI is an endless process, not a goal.

And paper is not better, net. Not by a long shot. Neither for patients nor any other stakeholders.
BTW, Dr. McNoble has launched a blog over on the platform:
Welcome to Bad Medicine
Bad Medicine is intended to help patients obtain the best possible medical care and to best utilize their precious health care dollars. Sadly, there are many barriers which seemed designed to get between patients and good health care — hospital bureaucracies, insurance authorizations, physicians overcrowded schedules, incomprehensible electronic health records, lack of network providers. In this series of blogs I am going to try to address some of these problems and provide practical advice for obtaining the best and most thorough medical care…
I wish her well with this effort. Hope she gets traction.



From THCB:
Single-Payer is the American Way

As is customary for every administration in recent history, the Trump administration chose to impale itself on the national spear known as health care in America. The consequences so far are precisely as I expected, but one intriguing phenomenon is surprisingly beginning to emerge. People are starting to talk about single-payer. People who are not avowed socialists, people who benefit handsomely from the health care status quo seem to feel a need to address this four hundred pound gorilla, sitting patiently in a corner of our health care situation room. Why?...
Interesting. She voted for Trump. Self-avowed "Liberal to the left of Bernie." See her interesting earlier post on her own blog,"The Legend of Health Care."


In my inbox today from Scientific American:
First Human Embryos Edited in the U.S., Scientists Say
Reports suggest researchers have altered DNA and made few errors

In a step that some of the nation’s leading scientists have long warned against and that has never before been accomplished, biologists in Oregon have edited the DNA of viable human embryos efficiently and apparently with few mistakes, according to a report in Technology Review.

The experiment, using the revolutionary genome-editing technique CRISPR-Cas9, was led by Shoukhrat Mitalipov of Oregon Health & Science University. It went beyond previous experiments using CRISPR to alter the DNA of human embryos, all of which were conducted in China, in that it edited the genomes of many more embryos and targeted a gene associated with a significant human disease.

“This is the kind of research that is essential if we are to know if it’s possible to safely and precisely make corrections” in embryos’ DNA to repair disease-causing genes,” legal scholar and bioethicist R. Alta Charo of the University of Wisconsin, Madison, told STAT. “While there will be time for the public to decide if they want to get rid of regulatory obstacles to these studies, I do not find them inherently unethical.” Those regulatory barriers include a ban on using National Institutes of Health funding for experiments that use genome-editing technologies in human embryos.

The first experiment using CRISPR to alter the DNA of human embryos, in 2015, used embryos obtained from fertility clinics that had such serious genetic defects they could never have developed. In the new work, Technology Review reported, Mitalipov and his colleagues created human embryos using sperm donated by men with the genetic mutation that they planned to try to repair with CRISPR. The embryos are described as “clinical quality.”…
Wow. Things are moving quickly.

More to comes...