Health Futures Blog
2 weeks ago
permalink
Cold War with Russia Heats Up
In a serious escalation of Russia’s conflict with the US, Russian inspectors have begun closing McDonalds restaurants for “code violations”.  http://online.wsj.com/articles/russia-shuts-eight-macdonalds-restaurants-as-tensions-rise-1409306882?mod=WSJ_hppMIDDLENexttoWhatsNewsSecond  
This could probably have been justified on public health grounds, but it seems to be politically motivated: striking at one of the most visible international symbols of corporate America.   US officials will be hard pressed to find a reciprocal action …  asymmetrical warfare is like that!

Cold War with Russia Heats Up

In a serious escalation of Russia’s conflict with the US, Russian inspectors have begun closing McDonalds restaurants for “code violations”.  http://online.wsj.com/articles/russia-shuts-eight-macdonalds-restaurants-as-tensions-rise-1409306882?mod=WSJ_hppMIDDLENexttoWhatsNewsSecond  

This could probably have been justified on public health grounds, but it seems to be politically motivated: striking at one of the most visible international symbols of corporate America.   US officials will be hard pressed to find a reciprocal action …  asymmetrical warfare is like that!

permalink
Onion:  More People Putting Off Retirement Until Last Few Moments of Life
As fewer older people have adequate retirement savings or sufficient Social Security income, more are putting off retirement until the last minute.  The Onion quotes a Bureau of Labor Statistics spokesman:  “Retirement’s different for everyone—some people may finish up working and then live off Social Security benefits for a few moments before passing on, while others might be able to lead active retired lives that last an entire afternoon. After a lifetime of working tirelessly to support themselves and their families, being able to enjoy several dozen seconds of retirement is a much-needed reward for most Americans.”
Actually, not funny…

Onion:  More People Putting Off Retirement Until Last Few Moments of Life

As fewer older people have adequate retirement savings or sufficient Social Security income, more are putting off retirement until the last minute.  The Onion quotes a Bureau of Labor Statistics spokesman:  “Retirement’s different for everyone—some people may finish up working and then live off Social Security benefits for a few moments before passing on, while others might be able to lead active retired lives that last an entire afternoon. After a lifetime of working tirelessly to support themselves and their families, being able to enjoy several dozen seconds of retirement is a much-needed reward for most Americans.”

Actually, not funny…

2 weeks ago
permalink
Hope:  Not a Strategy

Hope:  Not a Strategy

1 month ago
permalink
Gunfight at the Golden Corral
Those looking for reassurance that we in the United States remain deeply weird can look no further than this article about restaurants in the US that run promotions for patrons who wear guns to dinner: http://online.wsj.com/articles/smaller-eateries-serve-up-welcome-for-guns-1407108503?mod=outsidein
Perhaps we’ve reached a kind of frontier of market segmentation.As a gun owner, I’m as much for the right to bear arms as the next man.  But I hadn’t yet fully appreciated the synergy between guns and family dining.    It is reassuring that one owner comments:  ”Most that come in are responsible and have their guns holstered (italics added).”   Another sent home someone who walked in with an AR-15!  
Somalia, Afghanistan, Central African Republic… .Virginia Beach???  Think of the stories those Norwegian tourists will bring home to Oslo…

Gunfight at the Golden Corral

Those looking for reassurance that we in the United States remain deeply weird can look no further than this article about restaurants in the US that run promotions for patrons who wear guns to dinner: http://online.wsj.com/articles/smaller-eateries-serve-up-welcome-for-guns-1407108503?mod=outsidein

Perhaps we’ve reached a kind of frontier of market segmentation.As a gun owner, I’m as much for the right to bear arms as the next man.  But I hadn’t yet fully appreciated the synergy between guns and family dining.    It is reassuring that one owner comments:  ”Most that come in are responsible and have their guns holstered (italics added).”   Another sent home someone who walked in with an AR-15!  

Somalia, Afghanistan, Central African Republic… .Virginia Beach???  Think of the stories those Norwegian tourists will bring home to Oslo…

1 month ago
permalink
2 months ago
permalink
Why I Abandoned Facebook!
No, I cannot “predict”the future.  No-one can.  But my six months of posting on Facebook just didn’t feel right.  It wasn’t the constant nagging pressure to find some sunny personal anecdotes to share with my “friends”.  I was definitely uncomfortable with the core unvoiced expectation of the medium: self-disclosure, which is a genetically based discomfort for me.  It was something deeper:  that nagging question of what their 6000 plus employees were doing, beyond trying unobtrusively to insert commercial messages into my life so their stock would be worth billions. Now we know:  they were fiddling with our lives by manipulating our news feeds to see how it affected us: http://online.wsj.com/articles/facebook-experiments-had-few-limits-1404344378?mod=WSJ_hp_RightTopStories  .  Things like finding out how “political mobilization messages” caused people to vote in Congressional elections, on the “causes of loneliness” and on how fiddling the balance of positive and negative stories could cause depression.  
According to Sheryl Sandberg, Facebook’s stylish, business-facing spokesperson, it was all kosher:  simply "part of ongoing research companies do to test different products".  Bloody rubbish!  As a former member of their Data Sciences team said, bluntly, "They’re always trying to alter peoples’ behavior."   Another said: it is “the largest field study in the history of the world.”   Sandberg’s legalistic justification:  it was covered by the user agreement people “signed” when they opened their accounts.   
Social scientists sometimes succumb to the temptation to play God.  There were scandals in the late 1950’s, by a former graduate adviser of mine,  involving audiotaping jury deliberations without the jurors’ knowledge or consent to study influence patterns in their decision making, a linear ancestor of the now-revealed Facebook business practice.     
People participating in experiments should, like sentient beings with constitutionally guaranteed privacy rights, consent to doing so.  Informed consent is part of the social compact required by a code of responsible conduct of any research scientist.  
Jaron Lanier, a tech visionary and gadfly, warned us about the abuses of power possible in an age of “siren servers” in his 2013 book, “Who Owns the Future” -what we trade by surrendering our privacy to the benevolent overlords of cyberspace.  Wake up, users, and smell their arrogance. 

Why I Abandoned Facebook!

No, I cannot “predict”the future.  No-one can.  But my six months of posting on Facebook just didn’t feel right.  It wasn’t the constant nagging pressure to find some sunny personal anecdotes to share with my “friends”.  I was definitely uncomfortable with the core unvoiced expectation of the medium: self-disclosure, which is a genetically based discomfort for me.  It was something deeper:  that nagging question of what their 6000 plus employees were doing, beyond trying unobtrusively to insert commercial messages into my life so their stock would be worth billions. 

Now we know:  they were fiddling with our lives by manipulating our news feeds to see how it affected us: http://online.wsj.com/articles/facebook-experiments-had-few-limits-1404344378?mod=WSJ_hp_RightTopStories  .  Things like finding out how “political mobilization messages” caused people to vote in Congressional elections, on the “causes of loneliness” and on how fiddling the balance of positive and negative stories could cause depression.  

According to Sheryl Sandberg, Facebook’s stylish, business-facing spokesperson, it was all kosher:  simply "part of ongoing research companies do to test different products".  Bloody rubbish!  As a former member of their Data Sciences team said, bluntly"They’re always trying to alter peoples’ behavior."   Another said: it is “the largest field study in the history of the world.”   Sandberg’s legalistic justification:  it was covered by the user agreement people “signed” when they opened their accounts.   

Social scientists sometimes succumb to the temptation to play God.  There were scandals in the late 1950’s, by a former graduate adviser of mine,  involving audiotaping jury deliberations without the jurors’ knowledge or consent to study influence patterns in their decision making, a linear ancestor of the now-revealed Facebook business practice.     

People participating in experiments should, like sentient beings with constitutionally guaranteed privacy rights, consent to doing so.  Informed consent is part of the social compact required by a code of responsible conduct of any research scientist.  

Jaron Lanier, a tech visionary and gadfly, warned us about the abuses of power possible in an age of “siren servers” in his 2013 book, “Who Owns the Future” -what we trade by surrendering our privacy to the benevolent overlords of cyberspace.  Wake up, users, and smell their arrogance. 

2 months ago
permalink
3 months ago
permalink
Why is this our Problem?
This week, the world caught up to the explosive advance of an ultra-radical and violent Sunni militant group, ISIS, into central Iraq, rolling up an ineffectual Iraqi army and, in its wake, executing hundreds of Iraqi citizens.   ISIS, which grew in eastern Syria as a jihadist participant in the uprising against the Syrian government, has declared its intention to create a Sunni controlled caliphate covering a large part of both countries. That caliphate will be a breeding ground for a new generation of ultra-violent terrorists who will threaten the region and, eventually, US interests and citizens.  
The sudden rise of this group, which was cast out of Al-Qaeda because of its violence against Arabs,  poses a huge challenge to the United States. What is happening now in Iraq is, sadly and inexcusably, in major part our fault. Sunni-Shiite tensions go back thirteen hundred years; they are not new.  But by invading Iraq in 2003, we destroyed an existing, albeit brutal, government.     By abruptly withdrawing in 2011 without a status-of-forces agreement and without, therefore, any leverage to affect Iraq’s development, we created a power vacuum which has degenerated into a full blown civil war.      Now the charnel house of Syria will have an eastern neighbor.  
However flawed the logic of our invasion of Iraq, we placed the lives of forty million Iraqis at risk and put hundreds of thousands of Americans in harm’s way on the premise of limiting a terrorist threat and helping build a new Iraq.    Because we failed to invest the resources and political muscle to leave behind something sustainable, we created the conditions that led to mass executions and sectarian bloodshed.   We left Iraq because it was politically convenient and  before there was a sustainable alternative to the vile regime we overthrew.  
The American people want no further part of this conflict.  Over on POLITICO, 79% of respondents want no part of the Iraqi civil war we started.  That doesn’t mean our hands are clean.   Why did 4500 Americans have to die for this unfortunate country?  Why did we spend nearly a trillion in direct costs on our involvement in Iraq?  To leave behind a legacy of chaos and broken promises?    If we are going to involve ourselves in other countries’ problems, we cannot afford to make things worse by our intervention.   Otherwise, no one anywhere will trust us.
It is clear what need to happen, whether it is politically popular or not.  We are going to have to get busy with the Kurdish Peshmerga fighters, the moderate Syrian opposition and whoever else will help to eradicate ISIS, and use our influence with Nouri Al-Malki’s government to create a viable,inclusive political process in Iraq or else press to replace him. Otherwise, the 4500 young people we sent over there will have died for nothing.  And the world will be less safe for their sacrifices than it was before.  

Why is this our Problem?

This week, the world caught up to the explosive advance of an ultra-radical and violent Sunni militant group, ISIS, into central Iraq, rolling up an ineffectual Iraqi army and, in its wake, executing hundreds of Iraqi citizens.   ISIS, which grew in eastern Syria as a jihadist participant in the uprising against the Syrian government, has declared its intention to create a Sunni controlled caliphate covering a large part of both countries. That caliphate will be a breeding ground for a new generation of ultra-violent terrorists who will threaten the region and, eventually, US interests and citizens.  

The sudden rise of this group, which was cast out of Al-Qaeda because of its violence against Arabs,  poses a huge challenge to the United States. What is happening now in Iraq is, sadly and inexcusably, in major part our fault. Sunni-Shiite tensions go back thirteen hundred years; they are not new.  But by invading Iraq in 2003, we destroyed an existing, albeit brutal, government.     By abruptly withdrawing in 2011 without a status-of-forces agreement and without, therefore, any leverage to affect Iraq’s development, we created a power vacuum which has degenerated into a full blown civil war.      Now the charnel house of Syria will have an eastern neighbor.  

However flawed the logic of our invasion of Iraq, we placed the lives of forty million Iraqis at risk and put hundreds of thousands of Americans in harm’s way on the premise of limiting a terrorist threat and helping build a new Iraq.    Because we failed to invest the resources and political muscle to leave behind something sustainable, we created the conditions that led to mass executions and sectarian bloodshed.   We left Iraq because it was politically convenient and  before there was a sustainable alternative to the vile regime we overthrew.  

The American people want no further part of this conflict.  Over on POLITICO, 79% of respondents want no part of the Iraqi civil war we started.  That doesn’t mean our hands are clean.   Why did 4500 Americans have to die for this unfortunate country?  Why did we spend nearly a trillion in direct costs on our involvement in Iraq?  To leave behind a legacy of chaos and broken promises?    If we are going to involve ourselves in other countries’ problems, we cannot afford to make things worse by our intervention.   Otherwise, no one anywhere will trust us.

It is clear what need to happen, whether it is politically popular or not.  We are going to have to get busy with the Kurdish Peshmerga fighters, the moderate Syrian opposition and whoever else will help to eradicate ISIS, and use our influence with Nouri Al-Malki’s government to create a viable,inclusive political process in Iraq or else press to replace him. Otherwise, the 4500 young people we sent over there will have died for nothing.  And the world will be less safe for their sacrifices than it was before.  

4 months ago
permalink

Reaching a Rwanda Moment?

The fact that this photo of the queue for food aid to the Yarmouk refugee camp in Syria, was actually challenged by folks who thought it was photoshopped should tell you something about the contemporary Western mindset about this conflict.  YES, those really are THOUSANDS of starving people,  caught in the charnel house of the Syrian Civil War.

 And starvation, barrel bombs full of metal shards dropped by helicopter on residential neighborhoods,  poison gas, “industrial scale’ torture, missile strikes on schools and hospitals… are all weapons used by the Assad regime against its own people.

Samantha Power, the US Ambassador to the UN, who made her academic reputation with a searing portrayal of the Clinton administration’s failure to act in Rwanda, made a speech at the Holocaust Museum about international inaction in Syria: http://www.nytimes.com/2014/05/14/world/middleeast/syrian-crisis.html suggesting that we’ve reached a “Rwanda” moment in the crisis.

The President has portrayed this as a choice between what we’re doing- basically nothing- and “boots on the ground”.   It is a false and inhumane choice.  This isn’t Vietnam.  It isn’t Afghanistan.  Syria was a civilized country full of human beings ruled by a rapacious and immoral regime.   We have tremendous influence in the world, and it’s time to use it to bring this conflict to a close.  Five million refugees, unspeakable carnage.   Enough.

4 months ago
permalink
A Modest Proposal:  Charting Day  
By Jeff Goldsmith, Ph.D.
 At the end of March, Congress decreed a year-long postponement of the implementation of ICD-10, a remarkably detailed and arcane new coding scheme providers would have been required to use in order to get paid by any payer in the US (“bitten by orca” is but one of the sixty thousand new codes http://www.icd10data.com/ICD10CM/Codes/V00-Y99/W50-W64/W56-/W56.21XD).   The year postponement gives caregivers and managers a little more time to prepare for a further unwelcome increase in the complexity of their non-patient care activities.
 In the spirit of Jonathan Swift, who famously proposed in 1729 that the Irish sell their children as a food crop to solve the country’s chronic poverty problem (http://andromeda.rutgers.edu/~jlynch/Texts/modest.html), I have a suggestion about how to cope with the steady rise in complexity of the medical revenue cycle. Beginning when ICD-10 is implemented, there should be no patient care whatsoever on Fridays, permitting nurses and physicians to spend the entire day catching up on their charting and documentation, and other administrative activities.
 Physicians (http://content.healthaffairs.org/content/32/11/1990.full) nurses (http://www.jacksonhealthcare.com/media-room/surveys/nurses-on-non-patient-care-2011.aspx), and others involved in patient care already spend at least a day a week of their time on this process now, but it is interspersed within the patient care workflow, constantly distracting clinicians and interrupting patient interaction.  Hospitals are solving this problem with a medieval remedy:  scribes (http://www.npr.org/blogs/health/2014/04/21/303406306/scribes-are-back-helping-doctors-tackle-electronic-medical-records)  who follow physicians around and enter the required coding and “quality” information into the patient’s electronic record on tablets.   Healthcare might be the only industry in economic history to see a decline in worker productivity as it automated.
 If we simply devoted an entire day to nothing but charting, documentation and other billing and administrative tasks, physicians’ offices could send their receptionists and supporting cast home, and spend their entire time on Fridays getting their bills out. Scribes would not be needed.  Physicians and nurses could spend 100% of their time Monday thru Thursdays with patients - listening, analyzing, educating and advising- the things they to add value in the first place.  Patients would appreciate having the caregivers’ full attention, and have more time to spend asking questions and fully understanding what they need to do to be healthy. They would simply have to time their visits to fit within the narrower access window.
 This solution would introduce certain logistical complexities.  For example, how would caregivers remember what to record hours or days later about individual patients?  Simple solution:  issue them those Star Trek-looking Bluetooth earpieces connected to their smart phones.  They could simply mutter continuously into the earpieces without breaking eye contact with patients.  Caregivers could snap a photo of the patient at the beginning of the encounter, and an app could synchronize the patient photo to the stream of muttering, providing the information necessary for the care giver to fill out their electronic charts on Fridays.  
But what about all those patients in the hospital?  Simple.  Send them home and ask them to come back on Monday.   Hospitals are spooky places on weekends where not much happens anyway, and most physicians are “virtual” on weekends in any case.  Hospitals could save a ton of money on reduced call pay.  Some patients won’t come back.   If patients are really sick, they can come back on Mondays to resume treatment.  
 For people in the ICUs too sick to send home, simply put them in medically induced comas to slow them down, and they can be managed remotely with virtual ICU software, with care administered by a skeleton crew of ICU nurses.  Emergency rooms can simply ask people to wait a little longer than they normally wait, and provide them tablets to amuse themselves on Facebook or play Candy Crush.  Time flies when you’re in cyberspace.  
 It may be that a single day might not suffice, in which case “charting day” could begin on Thursday afternoon, and patient care could resume again on Monday.   To make sure patients get the caregiver’s full attention Monday thru Thursday, you could print on the backs of their lab coats in big red letters, “If you can read this, text the following number and this visit will be free!”  That will assure that physicians and nurses don’t turn their backs on patients, as they do today, to get a jump start on their charting.
 Since healthcare is an irony-free zone, one can expect a lot of misunderstanding about this proposal.   But at some point, we need to sort out the two key missions of healthcare:  caregiving and feeding the chart.  A brighter line between these two demands on clinician time-one shrinking and the other growing- might help clarify what we expect from our dedicated but overburdened healthcare workforce.

A Modest Proposal:  Charting Day  

By Jeff Goldsmith, Ph.D.

 At the end of March, Congress decreed a year-long postponement of the implementation of ICD-10, a remarkably detailed and arcane new coding scheme providers would have been required to use in order to get paid by any payer in the US (“bitten by orca” is but one of the sixty thousand new codes http://www.icd10data.com/ICD10CM/Codes/V00-Y99/W50-W64/W56-/W56.21XD).   The year postponement gives caregivers and managers a little more time to prepare for a further unwelcome increase in the complexity of their non-patient care activities.

 In the spirit of Jonathan Swift, who famously proposed in 1729 that the Irish sell their children as a food crop to solve the country’s chronic poverty problem (http://andromeda.rutgers.edu/~jlynch/Texts/modest.html), I have a suggestion about how to cope with the steady rise in complexity of the medical revenue cycle. Beginning when ICD-10 is implemented, there should be no patient care whatsoever on Fridays, permitting nurses and physicians to spend the entire day catching up on their charting and documentation, and other administrative activities.

 Physicians (http://content.healthaffairs.org/content/32/11/1990.full) nurses (http://www.jacksonhealthcare.com/media-room/surveys/nurses-on-non-patient-care-2011.aspx), and others involved in patient care already spend at least a day a week of their time on this process now, but it is interspersed within the patient care workflow, constantly distracting clinicians and interrupting patient interaction.  Hospitals are solving this problem with a medieval remedy:  scribes (http://www.npr.org/blogs/health/2014/04/21/303406306/scribes-are-back-helping-doctors-tackle-electronic-medical-records)  who follow physicians around and enter the required coding and “quality” information into the patient’s electronic record on tablets.   Healthcare might be the only industry in economic history to see a decline in worker productivity as it automated.

 If we simply devoted an entire day to nothing but charting, documentation and other billing and administrative tasks, physicians’ offices could send their receptionists and supporting cast home, and spend their entire time on Fridays getting their bills out. Scribes would not be needed.  Physicians and nurses could spend 100% of their time Monday thru Thursdays with patients - listening, analyzing, educating and advising- the things they to add value in the first place.  Patients would appreciate having the caregivers’ full attention, and have more time to spend asking questions and fully understanding what they need to do to be healthy. They would simply have to time their visits to fit within the narrower access window.

 This solution would introduce certain logistical complexities.  For example, how would caregivers remember what to record hours or days later about individual patients?  Simple solution:  issue them those Star Trek-looking Bluetooth earpieces connected to their smart phones.  They could simply mutter continuously into the earpieces without breaking eye contact with patients.  Caregivers could snap a photo of the patient at the beginning of the encounter, and an app could synchronize the patient photo to the stream of muttering, providing the information necessary for the care giver to fill out their electronic charts on Fridays.  

But what about all those patients in the hospital?  Simple.  Send them home and ask them to come back on Monday.   Hospitals are spooky places on weekends where not much happens anyway, and most physicians are “virtual” on weekends in any case.  Hospitals could save a ton of money on reduced call pay.  Some patients won’t come back.   If patients are really sick, they can come back on Mondays to resume treatment.  

 For people in the ICUs too sick to send home, simply put them in medically induced comas to slow them down, and they can be managed remotely with virtual ICU software, with care administered by a skeleton crew of ICU nurses.  Emergency rooms can simply ask people to wait a little longer than they normally wait, and provide them tablets to amuse themselves on Facebook or play Candy Crush.  Time flies when you’re in cyberspace.  

 It may be that a single day might not suffice, in which case “charting day” could begin on Thursday afternoon, and patient care could resume again on Monday.   To make sure patients get the caregiver’s full attention Monday thru Thursday, you could print on the backs of their lab coats in big red letters, “If you can read this, text the following number and this visit will be free!”  That will assure that physicians and nurses don’t turn their backs on patients, as they do today, to get a jump start on their charting.

 Since healthcare is an irony-free zone, one can expect a lot of misunderstanding about this proposal.   But at some point, we need to sort out the two key missions of healthcare:  caregiving and feeding the chart.  A brighter line between these two demands on clinician time-one shrinking and the other growing- might help clarify what we expect from our dedicated but overburdened healthcare workforce.

Powered by Tumblr Designed by:Doinwork