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Wednesday, May 7, 2014

ICD-9: E922.9, E955.4, E956, E970, Health IT, public health, and the Second Amendment

Imagine coming across an EHR Social History sub-template like this:


Preposterous. First of all, notwithstanding the potential public health data mining utility of such information, it's illegal for a clinician to ask a patient about firearms possession and usage. The gun lobby made sure to have such a proscription inserted in the PPACA. to wit:
PPACA, consolidated:

SEC. 2717 [42 U.S.C. 300gg–17] ENSURING THE QUALITY OF CARE.

(b) WELLNESS AND PREVENTION PROGRAMS -- For purposes of subsection (a)(1)(D), wellness and health promotion activities may include personalized wellness and prevention services, which are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web-based intervention efforts for each of the program’s participants, and which may include the following wellness and prevention efforts:

(1) Smoking cessation.
(2) Weight management.
(3) Stress management.
(4) Physical fitness.
(5) Nutrition.
(6) Heart disease prevention.
(7) Healthy lifestyle support.
(8) Diabetes prevention.

PROTECTION OF SECOND AMENDMENT GUN RIGHTS -- As added by section 10101(e)(2)

(1) WELLNESS AND PRIVENTION PROGRAMS -- A wellness and health promotion activity implemented under subsection (a)(1)(D) may not require the disclosure or collection of any information relating to—

(A) the presence or storage of a lawfully-possessed firearm or ammunition in the residence or on the property of an individual; or
(B) the lawful use, possession, or storage of a firearm or ammunition by an individual.

(2) LIMITATION ON DATA COLLECTION -- None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used for the collection of any information relating to

(A) the lawful ownership or possession of a firearm or ammunition;
(B) the lawful use of a firearm or ammunition; or
(C) the lawful storage of a firearm or ammunition.

(3) LIMITATION ON DATABASES OR DATABANKS -- None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used to maintain records of individual ownership or possession of a firearm or ammunition.


(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR ELIGIBILITY FOR HEALTH INSURANCE

A premium rate may not be increased, health insurance coverage may not be denied, and a discount, rebate, or reward offered for participation in a wellness program may not be reduced or withheld under any health benefit plan issued pursuant to or in accordance with the Patient Protection and Affordable Care Act or an amendment made by that Act on the basis of, or on reliance upon—

(A) the lawful ownership or possession of a firearm or ammunition; or
(B) the lawful use or storage of a firearm or ammunition.

(5) LIMITATION ON DATA COLLECTIONS REQUIREMENTS FOR INDIVIDUALS -- No individual shall be required to disclose any information under any data collection activity authorized under the Patient Protection and Affordable Care Act or an amendment made by that Act relating to—

(A) the lawful ownership or possession of a firearm or ammunition; or
(B) the lawful use, possession, or storage of a firearm or ammunition.
[Emphases mine}
Moreover, in today's acrimonious 2nd Amendment climate, irrespective of the foregoing PPACA clauses, any EHR vendor providing such a template would likely get death threats. I've gotten them simply for posting this (below) online in weapons rights-related article comments sections and advocating for repeal of the 2nd Amendment, which I view as a dangerous anachronism -- a relic of a distant and very different time, one whose benefits are nil and lethal risks are empirically incontrovertible and legion.


Not kidding. One Keyboard Commando comedian warned me that "you'll change your attitude after we come and kick your front door down" and sent me URL links to jpegs showing automatic weapons and ammo caches. Another wrote "We'll be over to Antioch soon. Until then, sleep tight."

From a Salon.com article this morning:
Imagine you’re sitting in a restaurant and a loud group of armed men come through the door. They are ostentatiously displaying their weapons, making sure that everyone notices them. Would you feel safe or would you feel in danger? Would you feel comfortable confronting them? If you owned the restaurant could you ask them to leave? These are questions that are facing more and more Americans in their everyday lives as “open carry” enthusiasts descend on public places ostensibly for the sole purpose of exercising their constitutional right to do it. It just makes them feel good, apparently.
For instance, in the wake of the new Georgia law that pretty much makes it legal to carry deadly weapons at all times in all places, parents were alarmed when an armed man showed up at the park where their kids were playing little league baseball and waved his gun around shouting, “Look at my gun!” and “There’s nothing you can do about it.” The police were called and when they arrived they found the man had broken no laws and was perfectly within his rights to do what he did. That was small consolation to the parents, however. Common sense tells anyone that a man waving a gun around in public is dangerous so the parents had no choice but to leave the park.  Freedom for the man with the gun trumps freedom for the parents of kids who feel endangered by him.

After the Sandy Hook elementary school massacre, open carry advocates decided it was a good idea to descend upon Starbucks stores around the country, even in  Newtown where a couple dozen armed demonstrators showed up, to make their political point. There were no incidents.  Why would there be? When an armed citizen decides to exercise his right to bear arms, it would be reckless to exercise your right to free speech if you disagreed with them. But it did cause the CEO of Starbucks to ask very politely if these gun proliferation supporters would kindly not use his stores as the site of their future “statements.” He didn’t ban them from the practice, however. His reason? He didn’t want to put his employees in the position of having to confront armed customers to tell them to leave. Sure, Starbucks might have the “right” to ban guns on private property in theory, but in practice no boss can tell his workers that they must try to evict someone who is carrying a deadly weapon...
Anyone recall Nevada's absurd "Second Amendment Remedies" Senate candidate Sharron Angle? And more recently, we have the maudlin spectacle of the scofflaw Bunkerville Nevada rancher Cliven Bundy, the bumbling, inarticulate hero to a throng of fractious, equally delusional self-appointed "militia" irregulars?

"The second amendment in effect prevents the national government from destroying the militias of the states and preserves a personal right that is centuries old. Joel Barlow, the Connecticut wit and writer, in 1792 sagely declared that a tyrant disarms his subjects to "degrade and oppress" them, knowing that to be unarmed "palsies the hand and brutalizes the mind," with the result that people "lose the power of protecting themselves." But arms privately held can be dangerous to society. President George Washington once reminded Congress that "a free people ought not only be armed but disciplined." He meant that the militias of his time had to be under military authority or, in the frequently used phrase, should be "a well-regulated" militia. However, we no longer depend on militias, a fact that in some respects makes the right to keep and bear arms anachronistic. An armed public is not the means of keeping a democratic government responsible and sensitive to the needs of the people. As the Supreme Court said in 1951, in Dennis v. United States: "That it is within the power of Congress to protect the government of the United States from armed rebellion is a proposition which requires little discussion." Whatever hypothetical value there might be, the Court said, in the notion that a "right" against revolution exists against dictatorial government "is without force where the existing structure of the government provides for peaceful and orderly change." The Court added, "We reject any principle of government helplessness in the face of preparations for revolution, which principle, carried to its logical conclusion, must lead to anarchy."

The right to keep and bear arms still enables citizens to protect themselves against law breakers, but it is a feckless means of opposing a legitimate government. The so-called militias of today that consist of small private armies of self-styled superpatriots are entitled to their firearms but deceive themselves in thinking they can withstand the United States Army. The Second Amendment as they interpret it feeds their dangerous illusions. Even so, the origins of the amendment show that the right to keep and bear arms has an illustrious history connected with freedom even if it is a right that must be regulated."

Professor Leonard W. Levy. Origins of the Bill of Rights (pp. 148-149). Kindle Edition.
From my blog post Force Majeure?

We routinely capture and risk-analyze all manner of "lifestyle" data: smoking, alcohol, drug use, motorcycle-riding, skydiving, etc. I would add firearms possession and use to the EHR SHx templates.

I won't be holding my breath, though. In fact, I'll likely be threatened yet again for even suggesting it. Meanwhile, ICD-9 dx codes E922.9, E955.4, E956, E970 and their kin will continue to populate U.S. hospital EHRs post hoc at a rate of several hundred per day.

___

More to come...

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