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Sunday, June 16, 2019

On Father's Day

My first kid was born 51 years ago, her sister two years later, then their brother Matt (our last surviving child) 36 years ago.


Every day is Father's Day for me. Wishing all of you dads well.
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Friday, June 14, 2019

June 2019 EHR interoperababble update


From THCB:
Electronic health records (EHRs) are a polarizing issue in health reform. In their current form, they are frustrating to many physicians and have failed to support cost improvements. The current round of federal intervention is proposed rulemaking pursuant to the 21st Century Cures Act calls for penalties for “information blocking” and for technology that physicians and patients could use “without special effort.”

The proposed rules are over one thousand pages of technical jargon that aims to govern how one machine communicates with another when the content of the communication is personal and very valuable information about an individual. Healthcare is a challenging and unique industry when it comes to interoperability. Hospitals spend lavishly on EHRs and pursue information blocking as a means to manipulate the physicians and patients who might otherwise bypass the hospital on the way to health reform. The result is a broken market where physicians and patients directly control trillions of dollars in spending but have virtually zero market power over the technology that hospitals and payers operate as information brokers...
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The draft rules for interoperability, CMS, ONC, TEFCA, USCDI are over a thousand pages. Most of the complexity stems from a design that avoids direct patient direction and transparency the way we expect banking and other automated services. This approach fragments the patient and physician experience and poses privacy and security risks that may never be solved. On the other hand, an interoperability design based on patient-designated sharing with clinicians that voluntarily post their digital contact info (personal, group, or institution) works across the full range of patient data (behavioral, HIPAA, patient-generated) and provides patients and family caregivers the transparency and accountability over health services that we need. Allowing patients to specify their authorization server further simplifies things by enabling competition for the authorization service – a digital concierge – that would give market power to individuals and deliver the pro-competitive benefits the Rule seeks.
"Banking and other automated services?" I have to voice some dubiety with respect to that apples-to-oranges analogy. "Allowing patients to specify their authorization server further simplifies things by enabling competition for the authorization service." Right, so we'll still have multiple competing architectures.

"Interoperababble?"

A hardy perenennial.
No amount of calling point-to-point interfaced data exchange "interoperability" will make it so.

Interestingly, I've spent a good bit of the day trying (with frustratedly limited success) to download my medical records in anticipation of my first patient visit next week at Kaiser. Muir (my last provider system) is on Epic. Kaiser is on Epic. You'd think that would be easy. You'd be wrong. My hernia surgery a year ago was via a surgeon at Bass Medical Group. Owned now by Muir, but on a different platform still. The urologist who dx'd my prostate cancer in 2015 was with NorCal Urology. Bought by Muir, but using NextGen (I think they've now migrated). My radiation oncology tx group was Diablo Valley Oncology and Hematology. Yet another EHR platform, one whose patient portal is useless.

I'm just going to have to write my own summary "progress note," comprised of Active Problems, Active Meds, CC, PMH, PSH, HPI, FH, SH, etc., to save the new M.A. a bit of intake time.
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More to come...

Tuesday, June 11, 2019

Crowdfunding health care

This HuffPo piece caught my eye on my iPhone.

While health insurance or government programs like Medicaid and Medicare can shield against huge medical bills, massive debt and even bankruptcy, only the truly wealthy can feel secure that sickness won’t lead to financial ruin.

This is why thousands of Americans have turned to crowdfunding website GoFundMe in the last decade to help cover medical bills and related costs. HuffPost is profiling some of those people, and what their stories reveal about the shortcomings of the American health care system.

These are not feel-good stories.

That’s often how the news media cover these fundraisers ― focusing on the generosity of individuals giving rather than the systemic failures that created the need. While it’s hard not to be inspired by successful campaigns and the fortitude of those suffering through terrifying ordeals, such stories portray a chilling reality that Americans ― even those with good jobs and health insurance, can be one bad day away from financial ruin.

A serious disease can put financial strain on people even in countries with universal health care systems and strong safety nets. But the United States, which has neither of those things, leaves its residents uniquely vulnerable…
In my more cynical moments, I might have written the title as "Inside America's Go[Bleep]Yourself Health Care System."

Both of my late daughters died well beyond flat broke from their respective cancers. There was no "GoFundMe" in the 1990's when Sissy was ill. Her younger sister Danielle, however, got a bit of OoP and "bucket list" benefit in 2017-18 from a crowdsourcing account set up by one of her friends.

As I ponder my new Kaiser Permanente Medicare Advantage membership, my max annual OoP (out-of-pocket) caps at $6,700--plus monthly premiums of $51 ($612 for a year, even if I never use them, though I will have ongoing Rx co-pays).

I lost track of my 2018 OoP. Suffice to speculate that it was well beyond $6,700, in light of my hernia and SAVR surgeries. I know my (BS) "Chargemaster" 2018 tally on my final EoB was close to $600k.

Tangentially, as recently reported by STATnews, one family in Iowa took things to a whole 'nuther level:
When ‘right to try’ isn’t enough: Congress wants a single ALS patient to get a therapy never tested in humans
...“What about other patients who can’t afford this kind of access and don’t have this kind of political clout? Should people be contributing to a GoFundMe that is extremely unlikely to lead to benefit? What are we doing to patients when we advance this spirit of fighting disease at all costs?”
Read all of it, including the fractious comments. Tough, tough case.

UPDATE

 
How will we pay for the coming generation of potentially curative gene therapies?
Senator Bill Cassidy, MD (R-LA)


We have arrived at a special moment in health care. Innovative, life-changing gene therapies are here that will cure or ease debilitating diseases. Yet these expensive treatments are entering a market structure that was not built to price them…
...Life-changing gene therapies are coming. We must give thought now on how to determine the price of these innovative, new-age treatments and how to finance them to ensure that we realize their full, beneficial potential while also ensuring that society can pay for them...
Another good STATnews item. No amount of crowdfunding will suffice in this area. More broadly, there's a bit of "market" condundrum with respect to "precision / personalized medicine," no? A "market of one?"

UPDATE


Firewalled, but we get the point.

"The U.S. health system has been carefully structured, often through enabling legislation triggered by special interest groups, to allow the supply side of the health care sector to extract enormous sums of money from the rest of society. Nowhere is this clearer than with specialty drugs, whose prices per year of treatment now routinely exceed $100,000. Yet on Capitol Hill, this system has always had its staunch defenders, for obvious reasons."

Reinhardt, Uwe E.. Priced Out (pp. 145-146). Princeton University Press. Kindle Edition. September 2016 Princeton interieww.
TANGENTIALLY
The Worst Patients in the World
Americans are hypochondriacs, yet we skip our checkups. We demand drugs we don’t need, and fail to take the ones we do. No wonder the U.S. leads the world in health spending.


…For years, the United States’ high health-care costs and poor outcomes have provoked hand-wringing, and rightly so: Every other high-income country in the world spends less than America does as a share of GDP, and surpasses us in most key health outcomes.

Recriminations tend to focus on how Americans pay for health care, and on our hospitals and physicians. Surely if we could just import Singapore’s or Switzerland’s health-care system to our nation, the logic goes, we’d get those countries’ lower costs and better results. Surely, some might add, a program like Medicare for All would help by discouraging high-cost, ineffective treatments.

But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?...
Yeah. Recall my prior post "Can medicine be cured? Some views from across the Pond"
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More to come...

Sunday, June 9, 2019

Exploiting Doctors and Nurses


Danielle Ofri, MD, in the New York Times:
…If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don’t shirk. The system knows it, too, and takes advantage.

The demands on medical professionals have escalated relentlessly in the past few decades, without a commensurate expansion of time and resources. For starters, patients are sicker these days. The medical complexity per patient — the number and severity of chronic conditions — has steadily increased, meaning that medical encounters are becoming ever more involved. They typically include more illnesses to treat, more medications to administer, more complications to handle — all in the same-length office or hospital visit.

By far the biggest culprit of the mushrooming workload is the electronic medical record, or E.M.R. It has burrowed its tentacles into every aspect of the health care system.

There are many salutary aspects of the E.M.R., and no one wants to go back to the old days of chasing down lost charts and deciphering inscrutable handwriting. But the data entry is mind-numbing and voluminous. Primary-care doctors spend nearly two hours typing into the E.M.R. for every one hour of direct patient care. Most of us are now putting in hours of additional time each day for the same number of patients.

In a factory, if 30 percent more items were suddenly dropped onto an assembly line, the process would grind to a halt…
Read the entire piece. I've cited Dr. Ofri on numerous occasions and have read her books and articles.

 
The E.M.R. is now “conveniently available” to log into from home. Many of my colleagues devote their weekends and evenings to the spillover work. They feel they can’t sign off until they’ve documented all the critical details of their patients’ complex medical histories, followed up on all the test results, sorted out all the medication inconsistencies, and responded to all the calls and messages from patients. This does not even include the hours of compliance modules, annual mandates and administrative requirements that they are expected to complete “between patients.”
According to their latest available IRS 990 (2017), the CEO of the Health Information Systems Management Society "non-profit" trade association (HIMSS) is paid about $1.25 million a year. I'm sure he's a very busy person.
As must also be the CEOs of Johnson & Johnson and Pfizer, each of whom earn close to $30 million annually.
The average primary care doc makes about $225k, according to Medscape.

AN ICONIC GRAPHIC

Yeah, it's a decade old. I'm confident that the trend has neither flattened nor reversed.

UPDATE

Monday morning rounds. Saw this cited at The Incidental Economist:

What makes us healthy?
 

We have an intuitive sense that things like what we eat, how much we exercise, the quality of our water and air, and getting appropriate health care when sick all help us stay healthy, but how much do each of these factors matter?

Studies have also shown that our incomes, education, even racial identity are associated with health — so-called “social determinants of health.”


How much do social determinants matter? How much does the health system improve our health?
Certainly worth following. 'The Drivers."
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More to come...

Saturday, June 8, 2019

How good is Kaiser's Medicare Advantage plan?

Cheryl and I are fixin' to find out first-hand.

What are the Pros and Cons of Switching to a Medicare Advantage Plan?

Medicare Advantage, also known as Medicare Part C, makes it possible for people with Medicare Part A (hospital insurance) and Part B (medical insurance) to receive their Medicare benefits in an alternative way. Medicare Advantage plans are offered by private insurance companies contracted with Medicare and provide at least the same level of coverage that Medicare Part A and Part B provide.

You may be wondering which is the better choice: sign up for a Medicare Advantage plan or Original Medicare. There isn’t a simple answer because Medicare Advantage plans have key features that many people find attractive and other characteristics that may not match with your personal preferences and/or lifestyle…
Among the upshots of our recent move from the CA Bay Area to Baltimore was being involuntarily disenrolled from our SilverScript Medicare Part-D Rx coverage ("out of service area"), and seeing a huge premium increase in our high-deductible MediGap Part-F plans (mine was about 30% compared to last year).

During the Christmas holidays, through our future daughter in Law Eileen, we'd come to know Dr. George Brouillet, orthopedic surgeon and former President of the Maryland Medical Association. He provided us with a list of area internal med docs to check out.

None of them were taking new patients. So much for "unrestricted choice of doctors" vs "HMO."

We discussed taking a closer look at Kaiser Permanente. I'd covered a number of their HIT Conference presentations across the years, and then we got caregiver in-your-face close-up looks once Danielle was diagnosed in March 2017 (she'd signed up for KP the year before via "Covered California")

We attended a KP pitch presentation, and watched a version of this:


We ran the comparative numbers once home. No longer need Rx Part-D or our Humana Medigap monthly premiums. Net financial benefit, though, quickly becomes inscrutable.
Our KP sales rep was candid to say that we could compare their plan to that of their principal competitor--Johns Hopkins.
Kaiser is on Epic, as is Muir (where I've been a patient since 2013), so records interop transfer should be "relatively" straightforward.
BTW, KP's Maryland Advantage plan is essentially a hybrid Staff + Network "capitated/risk" HMO model. No "medical underwriting."
After a rough initial start (incompetent, indifferent Primary who should count herself lucky I didn't come after her license), Danielle's KP care was uniformly top-shelf, notwithstanding that Kaiser lost their shirts on her.

We signed up. We shall see how our experiences shake out. Stay tuned.
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More to come...

Thursday, June 6, 2019

Uh-oh, someone's "feeling dark lately."

Margalit is at it again. Cross-posted.

For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.

It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before.  The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.

At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.

Managing the Health Care Consumer
The most blatant attempt to throw people under the bus is the insanely brazen effort to remake medicine into a consumer industry. Patients, according to the narrative, are empowered when they spend their own money on health care. Increasing deductibles for health insurance, while also increasing premiums and limitting choice of service providers, is how we weaponize sick people in the war against rising health care prices. If enough diabetics choose to die rather than overpay for insulin, prices for the drug will surely go down eventually, because Southwest Airlines will come up with a disruptively innovative version of insulin that will not be as fancy, but it will be cheap enough to spur increased market participation and push Eli Lilly into bankruptcy. Any day now.

The return to pre-1965 days of consumerism in health care for the first $6,000 of medical expenditures was a good step forward, but the road to fully optimized profitability is long and full of terrors. Consumers are like goats. If left to their own devices, they will destroy your landscape in five short minutes. However, with proper guidance and supervision, they will clean and protect your property from the dangers of random wild fires. Managed Care insurance plans, coupled with high deductibles, ensure that consumers do not eat into your nice profits, while consuming enough garbage to keep your bottom line from going up in smoke.

From Volume to Value
Offloading risk to sick consumers is working relatively well by all accounts, but it is not working well enough, and it is not working for beneficiaries of public insurance where the consumer lever is rather short and limp. And so, we push the “provider” lever next. Once patients became consumers, their doctors, naturally, became providers. And just like empowered consumers, empowered providers should have some financial skin in this game. In the current system, you see, providers are just sitting there, placidly watching the register go cha-ching every ten, fifteen minutes like clockwork. If the consumer gets better, fine. If not, also fine. As long as there are no malpractice lawsuits, and the cash keeps flowing, providers are surely satisfied. How do policy makers and garden variety health care experts know this? Simple. It’s called projection.

Moving “from volume to value” does not mean moving from indiscriminate overconsumption to eclectic consumption of excellence. It means moving from lots of variably priced stuff to small amounts of cheap stuff. It means moving from assumed abundance to assumed scarcity. If you can find excellence at the Dollar Store, good for you. If you can’t, well, whatever. Saks Fifth Avenue is out of bounds. And your provider is supposed to enforce those boundaries, at his or her own risk. If you manage to sneak into Saks, your provider will be punished. If you stay where you belong, your provider will be rewarded. Simple. It’s called stewardship.

Global Budgets
This is not fair. Obviously. These very clever risk levers are based on wealth, and since we have massive wealth inequality, the levers are largely discriminatory. Wealthy providers couldn’t care less about adding or removing a dollar from each patient visit. Poorer providers can be driven out of business by a fifty cents difference in “reimbursement”.  Wealthy patients don’t have to become consumers at all. For patients who are not wealthy enough (or poor enough), even the Dollar Store is cost prohibitive. There is too much privilege at the top. The only fair solution is to shut down Saks Fifth Avenue completely. If everybody is forced into the Dollar Store, eventually the Dollar Store will get better. It will become as good as Saks, but at $1 prices, because the wealthy will demand it. Right.

Shuttering the Saks Fifth Avenue of health care is hard. You can’t just show up at Bayonne Medical Center one morning with a wrecking ball and have at it. Fortunately, the Medicare For All aficionados have a solution: Global Budgets. Once the Federal government controls all health care dollars, they give Saks Fifth Avenue a fixed amount of money to service all their customers for the year. The amount of money is calculated based on Dollar Store costs, with a little markup perhaps, so we don’t appear overly vindictive. Within a few months, you won’t be able to tell the difference between a Saks store and a Dollar Store, except maybe the crumbling façade from a bygone era. That’s how we rid ourselves of inequality and excess privilege, of course.

Remember when Paul Ryan and his evil acolytes proposed replacing the open-ended Medicaid financing model with block grants to States (i.e. fixed amount of Federal money to service all their Medicaid beneficiaries)? There is a one hundred percent overlap between the people who screamed about millions dying in the streets if Medicaid moves to block grants, and the people now climbing the Medicare For All barricades in support of global budgets. Rationing medical care for the poor, or “by ability to pay”, is immoral. Rationing medical care for everybody, regardless of ability to pay, is righteous. Simple. It’s called justice.

A Permanent Solution
It is not surprising that health insurance companies would look out for their bottom line at customers’ expense. After all, these are insurance companies, like home insurance or car insurance, which are notorious for continuously devising innovative ways to minimize current and future payouts. Perhaps it is also not too much of a shocker to see that government is at its best when working to eschew commitments made to its citizens. What should however give you pause is that both government and health insurers seem to have finally found a good way to coopt physicians into doing their bidding. Not all physicians, of course, but more than enough to make a permanent difference in the practice of medicine. Either due to misplaced fear or newfound conviction, your doctor’s prime directive now is to do no harm to the United States Treasury and the corporations for which it shills. 
Trump. Agghhh...

UPDATE ERRATUM


apropos of nothing. But, yeah, this is us. Notwithstanding our having rid ourselves of another 3/4ths of our hardcopy books prior to the Baltimore move.
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More to come...

Wednesday, June 5, 2019

On the DiMe

Just saw this at STATnews during my morning rounds. Joined.

The Digital Medicine Society (DiMe) is the professional society for the digital medicine community. Together, we drive scientific progress and broad acceptance of digital medicine to enhance public health. Our mission is to serve professionals at the intersection of the global healthcare and technology communities, supporting them in developing digital medicine through interdisciplinary collaboration, research, teaching, and the promotion of best practices.
Put in a permanent link here in my right hand links column.

Given that I'm a fussbudget of late for "definitions," I liked this:
Defining Digital Medicine
What is digital medicine?


Digital medicine describes a field, concerned with the use of technologies as tools for measurement, and intervention in the service of human health. Digital medicine products are driven by high-quality hardware and software that support the practice of medicine broadly, including treatment, recovery, disease prevention, and health promotion for individuals and across populations.

Digital medicine products can be used independently or in concert with pharmaceuticals, biologics, devices, or other products to optimize patient care and health outcomes. Digital medicine empowers patients and healthcare providers with intelligent and accessible tools to address a wide range of conditions through high-quality, safe, and effective measurements and data-driven interventions.

As a discipline, digital medicine encapsulates both broad professional expertise and responsibilities concerning the use of these digital tools. Digital medicine focuses on evidence-generation to support the use of these technologies...
Ahhh... "evidence."

As noted at Forbes:
The Digital Medicine Society Is Developing Evidence-Based Standards For Digital Health
Professional groups and industry-wide collaborations are emerging to drive the growth of healthcare innovation. The development of high-quality, evidence-based products and services is now being supported by the Digital Medicine Society (DiMe) as well as the existing Digital Therapeutic Alliance (DTA).

The use of digital tools for better diagnosis and outcomes is rapidly progressing. The global digital health market is expected to reach $223.7 billion within five years based on increasing penetration of mobile devices, remote patient monitoring, and growing demand for advanced information systems. These products could represent a fundamental shift in healthcare services and actionable data generation according to experts…
Check 'em out. Sign up. Follow DiMe on Twitter and LinkedIn.


Wonder what the folks at HIMSS think about this. Lots of synergy potential, I would think.

BTW, apropos, I finished Susan Hockfield's book:

For the last couple of decades, as a dean and then provost at Yale, and then as president and now president emerita of the Massachusetts Institute of Technology (MIT), I’ve had the privilege of looking over the scientific horizon, and what I’ve seen is breathtaking. Ingenious and powerful biologically based tools are coming our way: viruses that can self-assemble into batteries, proteins that can clean water, nanoparticles that can detect and knock out cancer, prosthetic limbs that can read minds, computer systems that can increase crop yield. 

These new technologies may sound like science fiction, but they are not. Many of them are already well along in their development, and each of them has emerged from the same source: a revolutionary convergence of biology and engineering. This book tells the story of that convergence—of remarkable scientific discoveries that bring two largely divergent paths together and of the pathbreaking researchers who are using this convergence to invent tools and technologies that will transform how we will live in the coming century. 

We need new tools and technologies. Today’s world population of around 7.6 billion is projected to rise to well over 9.5 billion by 2050. In generating the power that fuels, heats, and cools our current population, we’ve already pumped enough carbon dioxide into the atmosphere to change the planet’s climate for centuries to come, and we’re now grappling with the consequences. Temperatures and sea levels are rising, and large portions of the globe are plagued with drought, famine, and drug-resistant disease. Simply scaling up our current tools and technologies will not solve the daunting challenges that face us globally. How can we generate more abundant yet cleaner energy, produce sufficient clean water, develop more effective medicines at lower cost, enable the disabled among us, and produce more food without disrupting the world’s ecological balance? We need new solutions to these problems. Without them, we are destined for troubled times...

Hockfield, Susan. The Age of Living Machines: How Biology Will Build the Next Technology Revolution (pp. ix-x). W. W. Norton & Company. Kindle Edition.
Nice to read something evincing net rational optimism these days during a time of aggressive science/tech denialism,,. I would hope that cutting-edge biotechnologies ("living machines") make it into the DiMe mix.

JUNE 6TH OFF-TOPIC ERRATUM: D:DAY 75

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More to come...

Tuesday, June 4, 2019

KHIT Reporting from Body-More Murdaland

A.K.A. Baltimore, Maryland.


A "graffiti" screen shot from HBOs' 89 hour masterpiece "The Wire."

Back during my second tenure with the Nevada-Utah HealthInsight Medicare QIO (the 2005-2008 "DOQ-IT" initiative), I was sent to the eClinicalWorks Boston area HQ for a week of hands-on training on their eCW ambulatory EHR. One night while surfing the TV channels in my hotel room I ran across "The Wire." I'd not even been aware of it.

I was stunned, mesmerized, instantly hooked. I eventually bought the DVD box sets for all five seasons, and have watched each episode therein at least a dozen times. I can cite verbatim large swaths of the screenplay.

Yeah, I know. Get a life...

From The Wiki:
Set and produced in Baltimore, Maryland, The Wire introduces a different institution of the city and its relationship to law enforcement in each season, while retaining characters and advancing storylines from previous seasons. The five subjects are, in chronological order: the illegal drug trade, the seaport system, the city government and bureaucracy, education and schools, and the print news medium. The large cast consists mainly of actors who are little known for their other roles, as well as numerous real-life Baltimore and Maryland figures in guest and recurring roles. Simon has said that despite its framing as a crime drama, the show is "really about the American city, and about how we live together. It's about how institutions have an effect on individuals. Whether one is a cop, a longshoreman, a drug dealer, a politician, a judge or a lawyer, all are ultimately compromised and must contend with whatever institution to which they are committed."

Now Cheryl and I live here, in the venerable bucolic, Colonial "shire" that is the "Homeland District" not far from Johns Hopkins University. Mere blocks away, on the east side of the north/south York Road, police helicopters routinely circulate amid recurrent news reports of "shots fired." A recent NY Times article featured a graphic depicting a cluster of notably violent areas. Midway down was a cluster of central American countries--El Salvador, Guatemala, Honduras, Nicaragua--with the city of Baltimore right in the mix.

Whatever. I will be buying one of these t-shirts. Saw a huge mural poster on the wall of a church a couple of blocks from our house.


Repeatedly, when I tell locals that I just moved here, I get "condolences." "What? Why? Did you kill someone and have to escape California?"
Our son Matt lives here, in Pigtown with our delightful future daughter-in-law. She's a Baltimore native and an environmental engineer with the state of Maryland. They love it here. After Matt lost a second sister to cancer last year, he's our last kid standing. Moving close by was a no brainer. Our CusterFluck of a transcontinental journey is beginning to fade into a dull irritating memory. Baltimore it is. Gotta find ways to serve productively.
Baltimore is getting a lot of stuff right. Note my permanent links column hard link on the right above the fold--"Healthcare for the Homeless."

BTW, see also my April 22nd post "An #Earthday reflection from Baltimore."

I also need one of these for my yard. They're all over Homeland.


JUNE 15TH UPDATE ERRATUM

An outraged neighbor just posted about this bit of "witty" vandalism on Nextdoor.com.


I wouldn't be surprised if the perp was Biff from Delta House at Loyola University Maryland just down the street.
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More to come...