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Friday, October 28, 2016

Un-common Language... communications in healthcare.

Among the many issues in American healthcare is the inability to share information among medical providers… patients, care-givers, institutions. This takes on many different forms and has several causes. Both form and cause need to be addressed prior to resolving the underlying issues of healthcare quality and costs.
One of the main issues in the cause column is that the many Electronic Health Records (EHR) do not easily talk to each other. This is a result of each of the EHR development companies (eg: EPIC and Cerner among hundreds) preferring to keep their systems proprietary… and the healthcare providers accepting this lack of standardization, because they want to maintain control over their patients. In both situations, the silo affect is willful protection of their profitability… not patient care or cost control. There is no standard way to share information between the silos, absence of such a common communication tool will limit the ability to reduce costs and improve care in the future.
The second issue is that medical professionals and business entities do not utilize a standardized language to describe any part of healthcare. For example, the ubiquitous drug “aspirin” can be described in electronic health records (the taxonomy or ontology of the data) in as many as 72 different ways. This problem makes it very difficult to accurately communicate between silos of healthcare. It makes it virtually impossible to standardize in ways that facilitate data statistics and algorithms... therefore analytics and clinical studies are hamstrung.
In other industries (financial for example) there has been standardization that allows for communication and aggregation of information. One can easily establish a link between one’s bank, investment, insurance, tax and debt accounts, for example. But in healthcare, an individual has no way to pull together their historic medical records… physician visits; prescription history; blood and image diagnostic work; hospital surgery records; vaccinations, and so on. Even though federal law has established the requirement that a person be able to get access to her records… it is required only that they be emailed (with no requirement for promptness), faxed or mailed on a memory device. This makes the record unsearchable, and virtually unusable during emergent situations.
All of this lack of communication in healthcare means that a patient cannot actually ‘own’, and carry with them, their personal medical history. This leads to situations where treatments are delayed, or repeats of diagnostic studies are necessary… adding costs and exposure to radiation… never mind, inconvenience.
There are two ways that we can, in the USA, take control of our health record. The first will likely never happen… have the federal government mandate a standard communication format, and require on-line access to an individual’s medical records. While this was done at the start of the digital revolution in diagnostic imaging with a standard called DICOM, to which all medical manufacturers must comply in order to achieve FDA approval… it seems the electronic medical record software used by all institutions and physician offices is well beyond standardization.
The second way seems more achievable. By individuals demanding access to their medical records in a digital format, they can take control of their history. This would have to be done as an individual, or by some sort of aggregator. It is the future, but when will it come?
It is somewhat obscure to envision a state where we have our personal medical records in one place, accessible to anyone to whom we want to deed access. This could be for emergent situations; second opinions; predictive analysis and so on. But we must start somewhere.
By asking our medical providers to give us our digitized records, and keep them in one place, we have a start. At least then if we need them on short notice, they are in one place. This would include previous blood or other diagnostic tests. Medical images (CT, MRI, Xray and UltraSound) are all digital today, and copies can be maintained by the individual. Records of vaccinations, flu shots and such are also important to have in one place. It is a start, but not enough.

Wednesday, October 26, 2016

So what is the 2016 election really all about?

So what is the 2016 election really all about? 

As usual there are different things for different folks… from being a historic GOP or Dem full ballot voter; to those checking all the issues that impact them personally; and finding a candidate or ballot issue that matches each, as closely as is possible. This probably doesn’t give anyone satisfaction, since democracy is not that granular, therefore individual needs cannot be assuredly satisfied with a single vote.

Democracy is not many of the things we believe it to be. As an example, it is not a “majority rules” form of government… except in 22 countries of the world who require all eligible voters (usually based on age) that are listed here http://www.pbs.org/newshour/rundown/22-countries-voting-mandatory/ … In effect, the rest of the countries are being ‘ruled’ by the leadership of the winning political party that received the majority of the votes of those who did vote… Usually much less than 80%.

 An example of non-democratic voting processes, is the USA. In 2012 just 57.5% of eligible American voters actually cast a ballot. In 2000 only 54.2% voted in the election that ultimately put the USA into a war in 2001 that is (fifteen years later, it is still not over). Interestingly, the outcome of that election, was in effect, decided by only the nine members (5 – 4) of the Supreme Court of the USA (SCOTUS) that stayed a Florida State Supreme court decision of 4 – 3 and ultimately elected George W. Bush president. All of which means that a change of around 1,500 votes overcame the majority of the votes in the country based on the arcane Electoral College system established by the US Constitution Articles and its 12th Amendment. Hardly a democracy by the definition… but here I digress!

So, if one is not choosing to vote based on specific line item issues… what is a reasonable way to consider the election of 2016. It is relatively simple, in my opinion to see the number one issue on the minds of Americans… not war, not healthcare, not the deficit… it is more likely the issue of “government not working” at the federal level. Without attaching blame, let’s look at the mechanics of the “government not working” issue, and the resulting legislative acrimony.

To start, it is important to understand the structure of the US Government at the federal level. There is a separation of power between the President of the USA, the Congress and the Supreme Court of the USA. These three branches of government have different responsibilities that allow government to work (Congress) and to manage disagreements/interpret the US Constitution (Supreme Court of the USA, (SCOTUS))
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The President has certain responsibilities under the constitution. S/he is primarily responsible for any international agreements, policies and non-declared wars (the type of which most USA military activity in the 21st Century, have been). The President is also the “leader” of the administration of the country within the boundaries and laws established by the US Constitution and Congress. S/he is also the morale leader in times of trouble, and celebration.

 The ‘framers of the Constitution of the USA’ established the US Congress with its two houses… one, the Senate is made up of two Senators from each state (50 x 2 = 100, today). With an age requirement (30 years old), and six year terms (a third is replaced every two years). The Senate was established to take the edge off the House of Representatives (which is based on population dispersion). The Senate is perhaps intended to be the wiser, more sedate, less tumultuous governing body in congress. Because of that, it was also chosen to give the President ‘advice’ relative to international wars; the nomination of Federal Judges; and leaders of Federal Agencies. In these situations, they are also required to give ‘consent’ to the ‘major’ nominations like Supreme Court Nominees, Ambassadors and Cabinet Members.

The House of Representatives, on the other hand, is based on each state’s population density percentage of the national population (there are 435 members of the house… eg: 27 are from the populous New York State and only 8 from Wisconsin a much lower density population state); the members serve only two-year terms (however there are no limits to the number of terms a Representative can serve).

This makes the House more volatile and prone to swings in policy based on the happenings of the day. Things like unemployment, healthcare, education and other personal issues, often cause significant swings in the politics of this legislative body. The wisdom of the Senate which must pass each of the House of Representatives’ legislative recommendations, prior to it going to the President, for promulgation, was seen by the framers of the constitution as having a ‘calming’ effect.  

The President can refuse to sign into legislation (veto) policies to which s/he disagrees. The Congress can over-ride a veto with a two-thirds majority in both the Senate and the House of Representatives. President Obama’s vetoes, for example have been overturned only once in eight years. So the ‘veto’ is a big hammer that the President can swing on the Congress.

The foregoing is an overly-simplified version of what happens in the legislative process of the USA. It is however critical to understanding why government is not working. If the leadership of either the Senate or the House of Representatives (or both), is in disagreement with the President for political, economic or other reason, they have the ability to hold up any, and/or all new legislation the President wants to pass*. This is critical in the 2016 Presidential election, simply because promises made by a Presidential candidate may not necessarily be passed into legislation, if the leadership of the House and Senate cannot, or will not agree to it.

So in my opinion, there is only one issue in 2016 Federal Election… when a President is elected on November 8th, 2016, will s/he be able to accomplish the goals to which they aspire?

It is the structure of the government that may give us the answer, if the past 20-year-history can lead us to better judgement, in the future. The President of the USA, for all the apparent power s/he may seem to have, cannot move the country in a significant way, without having agreement with the Congress, and in many ways, the Supreme Court.

The twenty-year-trend has been toward polarization between the President and Congress, so legislation has been very slow to pass. Yet, clearly there are significant domestic issues that need to be addressed. Based on structure, it is my opinion that the only way to deal with the needs of the country (infrastructure, healthcare, domestic security, social security, education) is to elect a President who can manage the relationship with congress on a win/win basis. There is a secondary issue that ‘might’ help… that being, to elect a President and Congress (House and Senate) from the same party in order to get legislation flowing. Although absent managing the relationship with Congress, even same party officials often disagree on issues (Obama’s first term for example).
Primarily the election of a President should be based (again in my opinion):

1) on electing a person who has demonstrated the ability to understand and work with all branches of the federal government;
2) it is critical for the incumbent to also understand, and be capable of working with the military, Governors of State legislatures, municipal leaders and leaders of other countries
3)  on understanding that the USA is a daunting leadership quagmire, one that is very different from being a business or institution
4) knowing the gravitas of also carrying the mantel of decisions that perhaps could impact the globe… pollution, power, human migration and nuclear proliferation to mention a few.

The main crux of this note is that it is important to vote… but also to understand what is in the balance of our votes… and it will be the union of many votes that gets our Legislative Bodies to work with the Leadership through rightful and thoughtful use of our obligation.


Notes: * (an exception to this is the budget of the USA: there is legislation in place that states that if the new budget request from the President in any one year is not passed by a pre-determined date, the budget of the prior year is repeated).

This is an interesting website: https://ballotpedia.org/United_States_House_of_Representatives_elections,_2016



Thursday, October 13, 2016

USA Election 2016... things to consider...

The Election in the USA … this is a long post, but not when comparing the time to read it, and then “think” about the election, and the impact on our personal lives.

One should be sensitive to surroundings these days when ‘thinking’ about the 2016 Federal Election in the USA. I write ‘thinking’ about it because it has such a huge potential impact on the future of America… it is important to ‘think’ about what action to take in the voting booth.

The election is important because of things that can happen in the four-year term of the next President… as well as the long term impact of decisions made by the President, Congress and Supreme Court. This cycle will see significant global changes requiring the next President to wrestle with such issues as:

a)      a) in global life (human, animal and plants) because of environmental issues (weather, carbon fuels, global warming) that will strain not only relationships between countries, but between individuals within many countries
b)      b) strains in global/macro-economies because of the rise of major population areas’ (India, China, Brazil) economies through better education; lower and fluctuating wages; the impact of conflicts and resulting migration; the application of significant technological breakthroughs in machine learning and applications of the digital revolution and robots
c)      c)  the hierarchy of countries based on the ability of one of many to wage nuclear war and the change in propensity to use such weapons whether the country is a super-power or not… Russia, India, Pakistan, Ukraine, Israel, North Korea among others can deliver a weapon, somewhere in the world that could start a chain of events leading to disaster

 In the domestic cycle of four to eight years the next President has to make decisions that lean on each of the global issues above (among many others), and importantly lead and influence decisions that directly impact domestic life… such as developing and implementing strategies:
a)     *  to improve infrastructure such as highways, bridges, airports… in order to ensure there is not a breakdown in the ability to move goods and services
b)      * to protect the colossal amount of data developed by the government agencies from cyber attack
c)      to ensure the banking, patent, internet and investment systems are robust, fair and protected from conflicting influence.
d)      *to revamp the education systems and motivation to maximize the use of education by the population to regain leadership in technological and societal evolution
e)      * rebuild the delivery of quality, affordable medical services, and motivate the population to utilize more, healthy life-styles to reduce the costs of poor health on the economy
f)       * to manage the debt in a way that keeps it serviceable, without international leverage

The leverage that the President will need to use will be based on his/her ability to work through the various levels of government (municipal, state and federal), and the political parties, not to mention significant regional bias. A problem with the “big picture” issues above, is that all of them depend on the interaction of the layers of government and leadership of each, to get things done. Without effective up/down and across communications among the governments, things like policing, education, banking and so on, cannot be impacted or work effectively.

The most critical jobs of the President of the USA are in the areas of international affairs, defense of the homeland (military, environmental issues) and so on. In these, s/he can act somewhat independently as long as budgets are available. Beyond these, the President must work with Congress to accomplish the goals of his/her platform. If there is symmetry in the goals (based on the political numbers in the Senate and House of Representatives) of the two governing layers of the country, it is easier to accomplish shifts in strategy that are likely needed to move the country in a significant way.

Without getting too deep into the issues of governing with less symmetry, one can reasonably assume that it is important to have symmetry. When big change is needed in the USA (the issues listed above are “big change”) the President needs to have his/her party in control of both the Congressional House of Representatives and the Senate.

At the same time, the country needs to have a judicial system that is capable of timely decisions across the federal civil, criminal and family court structures. While this starts with the Supreme Court, it is important to have all levels of courts functioning. The next President will have the opportunity to nominate several new Justices to the courts, including the Supreme Bench… starting on Day One with a replacement that will again give the court nine justices.

So, these are large issues, and our vote in November looms larger with the reduction in days forward to make a decision… as I write this, we have 30 days before finally voting. The surroundings that I mentioned being sensitive to at the outset are important because the very process of becoming educated on the issues means listening to, watching or reading sources of information that also insert bias more than at any time in the past. The process of “reporting” is no longer pure enough to trust “reports”. In effect, much of what we get as “news” is in fact commentary.

So once one’s store of information on policies, personalities, status quo is informed, I think it is important to find a way to metabolize the available information and come up with a decision on how to vote the ticket that will be presented in the voting booth. This means voting what is called the “top of the ticket” for President… and the down ticket… for Senator, Congressman in each district, and Judges, mayors and for many different “issues” that are on the ballot around the country. There is interaction between the top and all of the others… but particularly the Senate and House… important interaction that can facilitate a rational President… or keep him/her in check if necessary.

It is very hard to get away from momentary influences and the situation this year seems more dynamic than in any election in which I have participated. But that dynamic nature means it is even more important to make an educated, thoughtful decision. The issues of personal conduct, in my opinion are important… what conduct, in what conditions are important in the elimination of a candidate anywhere on the ticket? Not for me to judge, but for us to contemplate.

This election is about avoiding a nuclear war, and the genocide of millions of people based on one or another leader’s whim. It is about ensuring resolution to awesome issues like global warming; human migration and suffering; potable water and safe food availability and so on. It is of course also about national issues… as listed here… but if America wants to be the big dog in the world, it has to get off the porch and become a welcome leader, again. Leadership isn’t about the bite anymore (too many nuclear warheads), it is about influencing rational development of our globe and beyond. 

This is what we are voting about in November… it is more than one’s personal benefit, although it is to some extent about that… if we count surviving in a nuclear environment; or one with “storms of the century”, every week; or a country turned on itself with its guns and money.

Along with these issues one can add that it is an obligation, as a citizen, to be an informed voter… and to vote. I hope each of us will.





Blueknowser

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Grad. Saint Mary's University, 1975, got into the medical device business initially in sales, then various management positions up to president, all in Medical Devices. I prefer therapy products over diagnostic, but they are all fun, and in a way have defined my life. I have now evolved, with help from my 35 year partner Lynnda with whom I now share every hour. I am into staying healthy, photography, kayaking, bicycling, gardening and two books a week. I wish I had gotten to this stage earlier!