Fabius Maximus:

Joe goes on like this for quite a while. For a more rational report of this news, turn to the NY Times: “N.Y.C. Death Toll Soars Past 10,000 in Revised Virus Count.”

“New York City, already a world epicenter of the coronavirus outbreak, sharply increased its death toll by more than 3,700 victims on Tuesday, after officials said they were now including people who had never tested positive for the virus but were presumed to have died of it. …

“The city and the state have at times differed in their counts of the dead in New York City. As of Monday, the state said that 7,349 had died of the virus in the city. City officials have complained that they are at the whim of the state, which has been slow to share the data it receives from hospitals and nursing homes. The state Health Department explained on its website that the discrepancy is caused by the city and state using ‘different data systems.’”

Fun fact! The NYC numbers were increased on April 14, a city of 8 million increasing its count of fatalities by “more than 3700.” On April 17, China increased its fatality count by 1,290 for a city of 11 million – a proportionally smaller increase. But the journalists reporting the story about China had amnesia about the NYC news from three days ago, although that gives important context for the NYC story.

Also note the effect of the large, complex, and often conflicting reporting systems in China and America. When this causes confusion (or chaos) in the US, it is business as usual. When it happens in China, conservatives growl about those untrustworthy yellow people.

Extremists undermining our society

The final numbers for employment and GDP take over a year to produce in the US, with its vast and expensive accounting apparatus. Expect only unreliable numbers during a pandemic by doctors trying to save lives (including their own), with accounting a lower priority.

Complex phenomena are not counted like apples – whether CPI, GDP, or deaths from COVID-19. The definitions and accounting systems for all of these are constantly in motion, changed to reflect new knowledge and new collection systems. Before test kits were widely available (January in China, April in the US), clinical data was used to distinguish COVID-19 from the flu. Shifting to test kits changed the nature of the numbers.

Wu Feng:

It was late at night on Jan. 24, the day after Wuhan went into lockdown, when I boarded a plane bound for the city as part of a 128-member medical support team sent from the southern Guangdong province to the epicenter of China’s COVID-19 epidemic. We received a brief training session the next day, and on Jan. 26, we were taken to the hospital ward where we would spend the next 54 days.

I’ve been a doctor in an intensive care unit for 12 years, and during that time I’ve dealt with all manner of serious diseases. But stepping into that ward was the most terrifying moment of my life.

The cleaning staff and security guards hired by the hospital — most of them contractors — were gone, and the hallways were covered in garbage bags and contaminated medical waste. The ward was staffed by a total of two ophthalmologists and two nurses who were expected to care for 85 critically ill patients in varying degrees of respiratory distress.

Most of these patients should have been in an ICU, not a converted inpatient clinic. That first day, we watched as one of the doctors did their best to save a patient near death. It was no use: The hospital didn’t have enough oxygen left.

Jaron Lanier & E. Glen Weyl:

The spread of the novel coronavirus and the resulting COVID-19 pandemic have provided a powerful test of social and governance systems. Neither of the world’s two leading powers, China and the United States, has been particularly distinguished in responding. In China, an initial bout of political denial allowed the virus to spread for weeks, first domestically and then globally, before a set of forceful measures proved reasonably effective. (The Chinese government also should have been better prepared, given that viruses have jumped from animal hosts to humans within its territory on multiple occasions in the past.) The United States underwent its own bout of political denial before adopting social-distancing policies; even now, its lack of investment in public health leaves it ill-equipped for this sort of emergency.

The response of the bureaucratic and often technophobic European Union may prove even worse: Italy, although far from the epicenter of the outbreak, has four times the per capita rate of cases as China does, and even famously orderly Germany is already at half China’s rate. Nations in other parts of the world, such as information-manipulating Iran, provide worse examples yet.

Taiwan’s success has rested on a fusion of technology, activism, and civic participation. A small but technologically cutting-edge democracy, living in the shadow of the superpower across the strait, Taiwan has in recent years developed one of the world’s most vibrant political cultures by making technology work to democracy’s advantage rather than detriment. This culture of civic technology has proved to be the country’s strongest immune response to the new coronavirus.

TECH FOR DEMOCRACY

The value of Taiwan’s tech-enabled civic culture has become abundantly clear in the current crisis. Bottom-up information sharing, public-private partnerships, “hacktivism” (activism through the building of quick-and-dirty but effective proofs of concept for online public services), and participatory collective action have been central to the country’s success in coordinating a consensual and transparent set of responses to the coronavirus. A recent report from the Stanford University School of Medicine documents 124 distinct interventions that Taiwan implemented with remarkable speed. Many of these interventions bubbled into the public sector through community initiatives, hackathons, and digital deliberation on the vTaiwan digital democracy platform, on which almost half the country’s population participates. (The platform enables large-scale hacktivism, civic deliberation, and scaling up of initiatives in an orderly and largely consensual manner.) A decentralized community of participants used tools such as Slack and HackMD to refine successful projects. (Much of our analysis is based on open interviews through these tools with leaders in the g0v community of civic hackers.)

Federal electronic medical record data sharing rules have been released, many years after the $38B+ federal taxpayer backdoor subsidy, which promised “interoperability”.

David Wahlberg:

Rick Pollack, CEO of the American Hospital Association, said in a statement Monday that the final ONC rule fails to protect patient information. “The rule lacks the necessary guardrails to protect consumers from actors such as third-party apps that are not required to meet the same stringent privacy and security requirements as hospitals,” he said.



Nick Hatt, a product designer at Madison-based health care data-sharing company Redox and a former Epic employee, said Epic “didn’t really get very much in the final (ONC) rule. The content did not change substantially, so it was kind of a win for the patient-access side.”

The rule requires full exports of patient data, beginning in three years, to patients or hospitals if requested, Hatt said. “You’re being asked to develop something that helps your customers switch from your software to someone else,” he said.

Also, screen shots of electronic medical records will become more public, which Epic didn’t want, Hatt said. “They really don’t want to have screen shots of their software out on the internet, and now essentially it’s illegal for them to put those kinds of clauses in their contracts,” he said.

But the scope of data that must be shared will be limited for two years, and companies such as Epic will be able to warn patients about the dangers of sharing data with third-party apps — changes that were in Epic’s favor, Hatt said.

The rules apply to scenarios such as patients wanting to share clinical data and check lab results with Apple’s Health app, Hatt said.



Epic has said the proposed ONC rule could threaten patient privacy and intellectual property, and increase health care costs. CEO Judy Faulkner urged customers to support a letter in opposition to the rule. More than 60 health system CEOs, including those at UW Health, UnityPoint Health-Meriter and Gundersen Health System, signed the letter sent in February to HHS Secretary Alex Azar.

Related:

1. Paying – Repeatedly – for Epic’s Walled Garden

2. Airdrop trumps $40B Taxpayer Medical Record Subsidies.

3. Madison’s Property Tax Base Growth; $38B+ Federal Taxpayer EMR Subsidy.

4. $37,920,077,070 in Taxpayer Electronic Medical Record Subsidies: 2009 – January 2018

5. Epic Electronic Medical Record Implementation: $100,000,000 for Stanford Hospital in 2005.

6. Epic Systems Clearing Storm Landscape Images.

7. A failed 2007 attempt to use Wisconsin taxpayer funds for electronic medical record subsidies.

7. More notes and links on Epic Systems and its founder: Judy Faulkner

8. Federal electronic medical record data sharing rules: 474 page pdf.

I recently compiled a bit of long term, personal medical history along with an image or two prior to meeting a new physician. I sought to share this digital information efficiently, and save everyone time, if not money.

However and unfortunately, Epic Systems’ My Chart app (Madison, WI based UW Health implementation) lacks the ability to ingest and share patient sourced images or documents…..

A few days later, in clinic, I used iOS’s AirDrop to share the text and graphics to the physician’s iPhone. While helpful, the lack of patient sharing tools meant that a clinic visit was required along with ever increasing deductibles.

Many healthcare providers share personal medical record data via the iPhone’s health app.

However and unfortunately, $3.65B UW Health’s Epic medical records cannot be shared to my iOS health app.

We continue to pay more for less.

The lack of interoperability is a reminder that US taxpayer’s now $40B back door electronic medical record subsidy has been a failure. Costs have exploded and we citizens lack data portability, despite the legislation’s requirement:

The HITECH Act set meaningful use of interoperable EHR adoption in the health care system as a critical national goal and incentivized EHR adoption.[7][8] The “goal is not adoption alone but ‘meaningful use’ of EHRs—that is, their use by providers to achieve significant improvements in care.”[9]

There are pockets of innovation. One Medical’s app supports video visits:

Thankfully, the visit was of no consequence, other than time and money.

Additional reading:

Death By 1,000 Clicks: Where Electronic Health Records Went Wrong

Madison’s Property Tax Base Growth; $38B+ Federal Taxpayer EMR Subsidy

Stillborn 2007 Wisconsin $30M EMR subsidy.

Cringely:

A reader asked me to write tonight about the Health Information Technology for Economic and Clinical Health Act, which is about as far from something I would like to write about as I can imagine, but this is a full service blog so what the heck. The idea behind the law is laudable — standardized and accessible electronic health records to allow any doctor to know what they need to know in order to treat you. There’s even money to pay for it — $30 billion from the 2009 economic stimulus that you’d think would have been spent back in 2009, right? Silly us. Now here’s the problem: we’re going to go through that $30 billion and end up with nothing useful. There has to be a better way. And I’m going to tell you what it is.

Russ Britt:

The costly flaws in U.S. digital health-data plan

Recent news that Madison’s “total property values” top Milwaukee’s for the first time piqued my interest in the growing $38,220,758,479.00 federal taxpayer subsidy to organizations purchasing electronic medical records. Note that the $38B has been spent since 2011.

I created a chart illustrating Madison’s property tax base from 1977-2018 using data from the City Assessors office.

I displayed the federal taxpayer $38,220,758,479.00 (growing) subsidy from the date of the first payment (May, 2011) through June, 2018.

Tap for a larger version.

Background links:

How the Cleveland Clinic grows healthier while its neighbors stay sick .

Why Americans are avoiding the doctor.

On the Growth of Epic Systems:

Part of the company’s recent growth has stemmed from $30 billion in federal incentives included in the recovery act passed in 2009 during the financial crisis.

The incentives were designed to give a final shove to hospitals and physicians to make the costly and difficult transition from paper records to electronic records.

In 2008, only 1.5% of U.S. hospitals had a comprehensive system for electronic records implemented in all major clinical units, and an additional 7.5% had a basic system that included certain features in at least one unit, according to the results of a survey published in the New England Journal of Medicine.

Even fewer physician practices had made the transition.

By 2014, 75.5% of hospitals had at least a basic system, according to an annual survey.

Before the federal incentives, academic medical centers, hospitals that were part of health systems and large physician practices were most likely to have begun the transition to electronic health records. Epic focuses on those customers. But the incentives have contributed to the surge in the company’s growth.

That, though, has come at a price.

Epic’s size and success have made it a target for critics of electronic health records and the way the $30 billion federal program has evolved.

Critics contend that the systems are difficult to use, that entering information is time-consuming and detracts doctors from focusing on patients, that the records frequently are cluttered with unneeded information and that hospitals and physicians often can’t exchange information.

David Dranove, Craig Garthwaite, Christopher Ody, Bingyang Li:

In February 2009 the U.S. Congress unexpectedly passed the Health Information Technology for Economic and Clinical Health Act (HITECH). HITECH provides up to $27 billion to promote adoption and appropriate use of Electronic Medical Records (EMR) by hospitals. We measure the extent to which HITECH incentive payments spurred EMR adoption by independent hospitals. Adoption rates for all independent hospitals grew from 48 percent in 2008 to 77 percent by 2011. Absent HITECH incentives, we estimate that the adoption rate would have instead been 67 percent in 2011. When we consider that HITECH funds were available for all hospitals and not just marginal adopters, we estimate that the cost of generating an additional adoption was $48 million. We also estimate that in the absence of HITECH incentives, the 77 percent adoption rate would have been realized by 2013, just 2 years after the date achieved due to HITECH.

Subsidies given for computerizing, but no reporting required when errors cause harm:

President Obama and Congress poured $30 billion in taxpayer subsidies into the push for digital medical records beginning in 2009, with only a few strings attached and no safety oversight of the vendors who sell the systems.

The move was touted as a way to improve patient care and help rein in medical costs. Five years later, the explosion in the use of the electronic records has created the potential for efficiencies and safety benefits but also new risks for patients, the scope of which still is not fully understood.

But the scramble by doctors and hospitals to cash in on the incentives has thrust complex, balky, unwieldy, and error-prone computer systems into highly sensitive clinical settings at a record pace. From 2008 to 2013, the percent of US doctor’s offices with electronic health records rose from 17 to 48 percent. Growth in hospitals was even more dramatic, from 13 to 70 percent.

Mike Ivey:

Officials at Epic Systems are not commenting on a New York Times report Wednesday that the firm was central in lobbying Congress on a $19 billion “giveaway” (now $37B and growing) to convert all U.S. medical records from paper to computers.

The story contends that executives of the largest digital records companies — including Epic, Cerner and Allscripts — poured hundreds of thousands of dollars into a behind-the-scenes effort to promote the use of electronic records, effectively pushing aside smaller competitors.

Those efforts paid off handsomely in 2009, when legislation promoting the use of electronic medical records was included in President Obama’s economic stimulus bill. The $780 billion package included nearly $20 billion in incentives aimed specifically at software made by Epic and others.

The stimulus package also included penalties for doctors who don’t adopt the new technology. Providers who don’t install electronic records by 2014 will face reductions in their Medicare reimbursements.

2007 Then Wisconsin Governor Doyle’s proposed $30,000,000 state EMR subsidy.

Big Brother in the Exam Room: The Dangerous Truth about Electronic Health Records 1st Edition:

There are serious dangers lurking behind the government’s $30 billion electronic health record (EHR) experiment. This omnipresent technology turns doctors into data clerks and shifts attention from patients to paperwork–while health plans, government agencies, and the health data industry profit. Patients who think the HIPAA ”privacy” rule protects the confidentiality of their medical information will be shocked to discover it makes their medical records an open book.

City of Madison Assessor.

Unfortunately, this $38,220,758,479.00 and growing taxpayer subsidy has failed. We lack medical record interoperability and costs have continued to grow, substantially. US Federal Debt data…

I’ve found it curious that this far larger taxpayer subsidy has gone unmentioned when the $4B FoxConn subsidy has been tossed about within the political theatre.

Centers for Medicare & Medicaid Services:

Here’s where you’ll find Medicare and Medicaid Electronic Health Records Incentive Program payment and registration data in report form.

As of January 2018, more than 543,400 health care providers received payment for participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. In May 2013, CMS announced that more than half of all eligible health care providers had been paid under the Medicare and Medicaid EHR Incentive Programs.

The taxpayer outlay is updated monthly. January, 2018.

Background links:

How the Cleveland Clinic grows healthier while its neighbors stay sick .

Why Americans are avoiding the doctor.

On the Growth of Epic Systems:

Part of the company’s recent growth has stemmed from $30 billion in federal incentives included in the recovery act passed in 2009 during the financial crisis.

The incentives were designed to give a final shove to hospitals and physicians to make the costly and difficult transition from paper records to electronic records.

In 2008, only 1.5% of U.S. hospitals had a comprehensive system for electronic records implemented in all major clinical units, and an additional 7.5% had a basic system that included certain features in at least one unit, according to the results of a survey published in the New England Journal of Medicine.

Even fewer physician practices had made the transition.

By 2014, 75.5% of hospitals had at least a basic system, according to an annual survey.

Before the federal incentives, academic medical centers, hospitals that were part of health systems and large physician practices were most likely to have begun the transition to electronic health records. Epic focuses on those customers. But the incentives have contributed to the surge in the company’s growth.

That, though, has come at a price.

Epic’s size and success have made it a target for critics of electronic health records and the way the $30 billion federal program has evolved.

Critics contend that the systems are difficult to use, that entering information is time-consuming and detracts doctors from focusing on patients, that the records frequently are cluttered with unneeded information and that hospitals and physicians often can’t exchange information.

David Dranove, Craig Garthwaite, Christopher Ody, Bingyang Li:

In February 2009 the U.S. Congress unexpectedly passed the Health Information Technology for Economic and Clinical Health Act (HITECH). HITECH provides up to $27 billion to promote adoption and appropriate use of Electronic Medical Records (EMR) by hospitals. We measure the extent to which HITECH incentive payments spurred EMR adoption by independent hospitals. Adoption rates for all independent hospitals grew from 48 percent in 2008 to 77 percent by 2011. Absent HITECH incentives, we estimate that the adoption rate would have instead been 67 percent in 2011. When we consider that HITECH funds were available for all hospitals and not just marginal adopters, we estimate that the cost of generating an additional adoption was $48 million. We also estimate that in the absence of HITECH incentives, the 77 percent adoption rate would have been realized by 2013, just 2 years after the date achieved due to HITECH.

Subsidies given for computerizing, but no reporting required when errors cause harm:

President Obama and Congress poured $30 billion in taxpayer subsidies into the push for digital medical records beginning in 2009, with only a few strings attached and no safety oversight of the vendors who sell the systems.

The move was touted as a way to improve patient care and help rein in medical costs. Five years later, the explosion in the use of the electronic records has created the potential for efficiencies and safety benefits but also new risks for patients, the scope of which still is not fully understood.

But the scramble by doctors and hospitals to cash in on the incentives has thrust complex, balky, unwieldy, and error-prone computer systems into highly sensitive clinical settings at a record pace. From 2008 to 2013, the percent of US doctor’s offices with electronic health records rose from 17 to 48 percent. Growth in hospitals was even more dramatic, from 13 to 70 percent.

Mike Ivey:

Officials at Epic Systems are not commenting on a New York Times report Wednesday that the firm was central in lobbying Congress on a $19 billion “giveaway” (now $37B and growing) to convert all U.S. medical records from paper to computers.

The story contends that executives of the largest digital records companies — including Epic, Cerner and Allscripts — poured hundreds of thousands of dollars into a behind-the-scenes effort to promote the use of electronic records, effectively pushing aside smaller competitors.

Those efforts paid off handsomely in 2009, when legislation promoting the use of electronic medical records was included in President Obama’s economic stimulus bill. The $780 billion package included nearly $20 billion in incentives aimed specifically at software made by Epic and others.

The stimulus package also included penalties for doctors who don’t adopt the new technology. Providers who don’t install electronic records by 2014 will face reductions in their Medicare reimbursements.

Unfortunately, this $37,920,077,070, and growing taxpayer subsidy has failed. We lack medical record interoperability and costs have continue to grow, substantially.

UPDATE – Paper Trails: Living and Dying With Fragmented Medical Records by Ilana Yurkiewicz

UPDATE 2: Getting your medical records might not be easy:

“There were overwhelming inconsistencies in information relayed to patients regarding the personal health information they are allowed to request, as well as the formats and costs of release, both within institutions and across institutions,” said Carolyn Lye, the study’s first author.

“We also found considerable noncompliance with state and federal regulations and recommendations with respect to the costs and processing times,” Lye, a medical student, said in a university news release.

The researchers also found that 58 percent of the hospitals charged more than the federally recommended $6.50 for medical records stored electronically. One hospital charged $541.50 for a 200-page record.

The study was published online Oct. 5 in JAMA Network Open.

Stricter enforcement of the patients’ right of access is necessary to ensure that the request process across hospitals is easy to navigate, timely and affordable, Lye suggested.

Assessment of US Hospital Compliance With Regulations for Patients’ Requests for Medical Records by Carolyn T. Lye, Howard P. Forman, MD, MBA and Ruiyi Gao:

Among the 83 top-ranked US hospitals representing 29 states, there was discordance between information provided on authorization forms and that obtained from the simulated patient telephone calls in terms of requestable information, formats of release, and costs. On the forms, as few as 9 hospitals (11%) provided the option of selecting 1 of the categories of information and only 44 hospitals (53%) provided patients the option to acquire the entire medical record. On telephone calls, all 83 hospitals stated that they were able to release entire medical records to patients. There were discrepancies in information given in telephone calls vs on the forms between the formats hospitals stated that they could use to release information (69 [83%] vs 40 [48%] for pick up in person, 20 [24%] vs 14 [17%] for fax, 39 [47%] vs 27 [33%] for email, 55 [66%] vs 35 [42%] for CD, and 21 [25%] vs 33 [40%] for online patient portals), additionally demonstrating noncompliance with federal regulations in refusing to provide records in the format requested by the patient. There were 48 hospitals that had costs of release (as much as $541.50 for a 200-page record) above the federal recommendation of $6.50 for electronically maintained records. At least 7 of the hospitals (8%) were noncompliant with

Walking around Rome a short while ago, I pondered the words spoken by Christ (Luke 21) at this weekend’s Palm Sunday service:

5 Some of his disciples were remarking about how the temple was adorned with beautiful stones and with gifts dedicated to God. But Jesus said, 6 “As for what you see here, the time will come when not one stone will be left on another; every one of them will be thrown down.”

7 “Teacher,” they asked, “when will these things happen? And what will be the sign that they are about to take place?”

8 He replied: “Watch out that you are not deceived. For many will come in my name, claiming, ‘I am he,’ and, ‘The time is near.’ Do not follow them. 9 When you hear of wars and uprisings, do not be frightened. These things must happen first, but the end will not come right away.”

10 Then he said to them: “Nation will rise against nation, and kingdom against kingdom. 11 There will be great earthquakes, famines and pestilences in various places, and fearful events and great signs from heaven.

12 “But before all this, they will seize you and persecute you. They will hand you over to synagogues and put you in prison, and you will be brought before kings and governors, and all on account of my name. 13 And so you will bear testimony to me. 14 But make up your mind not to worry beforehand how you will defend yourselves. 15 For I will give you words and wisdom that none of your adversaries will be able to resist or contradict. 16 You will be betrayed even by parents, brothers and sisters, relatives and friends, and they will put some of you to death. 17 Everyone will hate you because of me. 18 But not a hair of your head will perish. 19 Stand firm, and you will win life.

20 “When you see Jerusalem being surrounded by armies, you will know that its desolation is near. 21 Then let those who are in Judea flee to the mountains, let those in the city get out, and let those in the country not enter the city. 22 For this is the time of punishment in fulfillment of all that has been written. 23 How dreadful it will be in those days for pregnant women and nursing mothers! There will be great distress in the land and wrath against this people. 24 They will fall by the sword and will be taken as prisoners to all the nations. Jerusalem will be trampled on by the Gentiles until the times of the Gentiles are fulfilled.

I pondered this while strolling past the Arch of Titus:

Wikipedia:

It was constructed in c. AD 82 by the Emperor Domitian shortly after the death of his older brother Titus to commemorate Titus’s victories, including the Siege of Jerusalem (AD 70).

The south panel depicts the spoils taken from the Temple in Jerusalem. The golden candelabrum or Menorah is the main focus and is carved in deep relief.[9] Other sacred objects being carried in the triumphal procession are the Gold Trumpets, the fire pans for removing the ashes from the altar, and the Table of Shew bread.[8] These spoils were likely originally colored gold, with the background in blue.[8] In 2012 the Arch of Titus Digital Restoration Project discovered remains of yellow ochre paint on the menorah relief.[10]

Palm Sunday.

Thomas Bagger:

“Germany is Weltmeister,” or world champion, wrote Roger Cohen in his July 2014 New York Times column1—and he meant much more than just the immediate euphoria following Germany’s first soccer world championship since the summer of unification in 1990. Fifteen years earlier, in the summer of 1999, the Economist magazine’s title story depicted Germany as the “Sick Man of the Euro.”2 Analysis after analysis piled onto the pessimism: supposedly sclerotic, its machines were of high quality but too expensive to sell in a world of multiplying competitors and low-wage manufacturing. Germany seemed a hopeless case, a country stuck in the 20th century with a blocked society that had not adapted to the new world of the 21st century, or worse, a society that was not even adaptable.
Things since then have changed significantly. In the summer of 2013, more than a year before the triumph in Rio de Janeiro, the Economist reversed its own verdict—Germany now appeared on the front page as “Europe’s Reluctant Hegemon.”3 In 2014, Germany came out on top for the second year in a row in the BBC’s annual country rating poll as the country with “the most positive influence on the world.”4 Simon Anholt’s annual “Nation Brand Index” also put Germany in the top spot in 2014.5