Ordering in Swahili at a French restaurant in Seoul

Bill Gardner at the Incidental Economist laments the state of electronic medical records today and contrasts it to a vertically integrated data exchange system that he used last week.

 the car has been worked on at several dealerships in several cities. And of course, I have no clear memory of what I’ve gotten done when.

No problem. The car has a VIN number. Dealerships are independent enterprises, but Toyota has an international database that has all the service records from all the dealerships. The service manager and I are looking at the records in seconds and we quickly make a decision about the needed service.

This is interesting only because I can’t do this for my body….

The engineering and legal work required to make electronic health records interconnect is harder than the engineering required to connect Toyota dealerships. Nevertheless, it is seriously stupid

I was able to speak with a medical informatics person for a while about this post and what she said was that right now most electronic medical record (EMR)systems are pretty good within their own silo. If you, as a patient, stay within one EMR ecosystem, the results are pretty decent.  Providers can see trends, they can see case notes, they can see allergies, and they can see any idiosyncracies about your medical history fairly easily.  Too many of the systems are still mainly focused on data management and not provider-patient interaction or even provider-computer interactions so too many appointments have the doc looking at a screen too much.  However, the back-end of any individual system on the market that has more than a couple major hospital groups using it is reasonably solid. 

The problem arises when you as a patient switch between environments.  If your primary care provider uses System 1 and your cardiologist just got bought out by a hospital group that uses its own in-house EMR system, the odds that those two systems will talk well with each other is slightly better than a Swahili speaking customer getting a perfect coq au vin in Seoul.  It is possible, just highly unlikely, that the righ set of crosswalks and translation protocol will be in place between the two systems.  Some of the larger systems will have rough translation protocols in place between systems, and there are developmental efforts to put a translation layer above a variety of EMR bases, but those systems are not widely deployed.

The big problem is simple for Toyota.  They keep everything vertically integrated and they make it a requirement that all the dealers in their network buy the same piece of software with the same protocols, the same data dictionaries, and the same agreed upon sets of meaning.  From here, it is just a nasty database management problem, and realistically, it is not too nasty as there is a unique key (the VIN) that already has external meaning.  EMRs in this country don’t have shared meaning, they don’t have shared data dictionaries, they don’t have shared formatting (for example,how do you write a date, as I can think of at least seven valid ways, three of which produce major screwups in other format systems), and they don’t share the same protocol. 

The VA gets around this problem because they are effectively in the same boat as Toyota.  Kaiser gets around this problem as they are a mini-NHS segregated from most of the US medical system.  Big players that own their own hospitals, doctors and insurance companies get around this problem as they can keep most of their patients in the same environment.  But crossing networks and getting the systems to talk to each other is an ugly problem.

Late Holiday-Weekend Saturday Night Open Thread

I fully agree with President Obama’s comments, per Buzzfeed:

Speaking at a private Democratic fundraiser in Purchase, N.Y., the president told donors, “if you watch the nightly news, it feels like the world is falling apart … And I can see why a lot of folks are troubled.”

But, Obama said, despite recent unrest in the Middle East, Russia’s apparent invasion of Ukraine, and the explosive growth of ISIS, “the truth of the matter is, is that the world has always been messy.”

“In part, we’re just noticing now because of social media and our capacity to see in intimate detail the hardships that people are going through,” the president told donors

“I promise you things are much less dangerous now than they were 20 years ago, 25 years ago or 30 years ago,” Obama said Friday. “This is not something that is comparable to the challenges we faced during the Cold War.”

I’d have used the “OLD MAN YELLS AT CLOUDS” tag, but you might have mistaken it as applying to the President and not just to me.

ETA: Because commentor Wasabi Gasp wanted music:

Get the basics right SATSQ

Is knowing what you’re talking about an automatic disqualification from writing about health policy at Forbes Magazine?

Josh Archambault at Forbes last June was advocating that Gov. Corbett (R-PA) pull the application for a waiver for Healthy PA because it was not reformy/screw the poor enough and fucks up some basic facts:

The flawed design of Healthy PA is also likely to result in higher costs to taxpayers.  Similar to the “Private Option” Medicaid expansion in Arkansas, enrollees under Healthy PA can purchase any “private coverage option” in their geographic area without any additional financial cost to themselves.

This provision alone could drive costs sky-high.  Enrollees have no financial incentive to keep costs low. In most regions of the state, the most-expensive plan costs more than twice as much as the least-expensive plan. Healthy PA enrollees are likely to flock to these Cadillac options, as they typically have broader provider networks and better prescription drug coverage. When enrollees pick these more expensive options, the tab picked up by taxpayers will skyrocket.

Wow, there is a lot of fail here.

Read more

Playing with lives (Healthy PA edition)

I need to call out some commenters from my previous thread on the Healthy PA waiver approval.


but I thought HHS shoulda just waited until after November.

I think you are wrong for multiple reasons here.  The first, is purely mechanical.  My old team (the insurance plumbers) gamed, over a long database modification weekend, what it would take (from our perspective) to set up a private option style system in our state.  We figured that to do it right (ie actually being able to enroll people, get the docs on board, and pay a claim the first week that we received it), we would want a six month heads-up, and could do it in three or four months with lots of coffee.  Seven weeks from the first day of claims payment eligibility and three weeks to enrollment after the final approval is either impossible or a fiasco in the making.  Proposing a blatantly political stunt means people needlessly are uncovered for an extra month or two.

Secondly, I think this type of stunt is subverting the democratic process.  Our system is designed for political actors to grab a popular chunk of the other guy’s platform/policy, tweak it slightly, relabel it and claim it as their own.  Corbett is engaged in simple politics that he is trying to neutralize his opponent’s popular policy plank by stealing as much of it as he can get away with.  This is normal, mostly rational give and take transactional politics in a high veto point system.  It is healthy.

Finally, Democrats and liberals are the ones who make the argument that government can and should work.  Deliberately making the government not work in an efficient manner is not a good idea.


I don’t think it is such good news. It is not as good as just straight medicaid, and It sets a starting bargaining position for the remaining states who have not yet allowed medicare. In the short run it enrolls more people, in the long run less people at greater expense to them and to the system.

Agreed, in a universe where the Supreme Court did not gut Medicaid expansion, this is distinctly second best.  We are not on that strand of the multiverse. I think your second argument that the Pennsylvania waiver approval weakens federal  bargaining position is a non-sequitor.  The Feds, at this point, are bargaining with states’ political actors who are not too enthused or committed to expansion.  The Feds want to make a deal, the state actors would not mind doing so, but don’t have to.  The party that can more easily walk away has the leverage irregardless without regard to what other parties agree to or not.  The Pennsylvania agreement may set some limits on what non-medical restrictions can be introduced into Medicaid waivers, but that merely limits hold-out states from asking for the moon.  It is minimally relevant for other hold-out states like Wyoming from asking for and getting private option like approval from CMS in the future.

The relevant comparison for Healthy PA is what is the next likely alternative.  Is it straight up Medicaid expansion (which from a plumbing POV should be simple and straightforward), or is it nothing?  In my opinion, no expansion is far more likely than straightforward expansion as the next preferred alternative.  And that will remain the case as long as the Teabaggers control at least one veto point in the state government. They are likely to hold at least one veto point for the rest of this decade.

So again, the question is no coverage for half a million people or pretty decent but sub-optimal coverage for half a million people and the creation of some very powerful stakeholders who will make sure expansion stays in place?  Anyways, Pennsylvania has been a Medicaid managed care state for years now, and the private option/premium support model had already been approved for other states, so it is not much of a precedent.  The shocker would have been full approval without restriction of the original waiver application or full denial, not a deal.

I think the basic question is a moral question that informs our policy judgement — what policy changes are severe enough to justify not covering a quarter million people in year one and half a million people in the out years?  In my opinion, mild inefficiency through skimming and sub-optimal but still pretty good benefit design does not even come close to raising that question.

Medicaid Expansion outlook for 2015

We’re starting to hit the point of no return for any states that want to expand Medicaid with a go live date of January 1, 2015.  A state that is authorized to expand Medicaid in anything other than a straight up expansion probably needs a good three to four months to get initial operating capacity built out.  They will need six to nine months to get everything working correctly after that.  A state that is doing straight up expansion based on current configuration can go live with minimal hassles with a month’s notice. 

So what is the state of play on Medicaid expansion for 2015. Read more

Tuesday Morning Open Thread: Women’s Equality Day

Lucy MacCalmont, at Politico:

President Barack Obama designated Tuesday as Women’s Equality Day, noting that women have made many advancements within the last century, but his administration is “committed to tearing down the barriers” that still exist.

“…[W]omen are succeeding like never before. Their contributions are growing our economy and advancing our nation,” Obama said in a statement on Monday, noting achievements in education, business and the armed forces. “But despite these gains, the dreams of too many mothers and daughters continue to be deferred and denied.”…

Obama said Women’s Equality Day, which marks the day in which the 19th Amendment was certified and gave women the right to vote, is to celebrate the achievement of women and promote gender equality…

“In the 21st century, a mother should be able to raise her daughter and be her role model—showing her that with hard work, there are no limits to what she can accomplish,” Obama said.

“When women are given the opportunity to succeed, they do,” Obama said.

Apart from remembering that progress has been made (if not always in a straight line), what’s on the agenda for the day?

Monday Morning Open Thread

And for something a little cheerful, here’s a genius example of popcult repurposing, as reported by the NYTimes:

LOS ANGELES — For a second year in a row, Miley Cyrus hijacked MTV’s Video Music Awards on Sunday night, and this time she did it without debauched dance moves or wild tongue gyrations. In fact, she did not even take the stage…

Near the end of Sunday’s live show, at the Forum in Inglewood, CA, when Jimmy Fallon announced that Ms. Cyrus’s “Wrecking Ball” had won video of the year, a longhaired man who said he was from Oregon and had recently been living on the streets of Hollywood appeared at the microphone. “My name is Jesse,” the young man said, reading from notes without mentioning his surname. “I am accepting this award on behalf of the 1.6 million runaways and homeless youth in the United States who are starving and lost and scared for their lives. I know, because I am one of those people.”

“I have survived in shelters all over this city,” he continued, before attempting to shame the music industry with a speech. “The music industry will make over $7 billion this year, and outside these doors are 54,000 human beings who have no place to call home.” (Los Angeles County estimates that it has a homeless population of roughly 54,000.)…

Ms. Cyrus, according to a representative, modeled Jesse’s appearance after Marlon Brando’s decision to have a woman named Sacheen Littlefeather accept his Best Actor Oscar for “The Godfather” in 1973 as a protest against the movie industry’s treatment of Native Americans.

As Jesse spoke, Ms. Cyrus’s representatives introduced via her social media channels a Prizeo.com fund-raising campaign for My Friend’s Place, an organization based in Los Angeles that helps homeless people from the ages of 12 to 25 find housing, jobs, health care and schooling. Those who make donations before Sept. 21 will be entered in a lottery. The prize: a chance to hang out with Ms. Cyrus when her Bangerz tour reaches Rio de Janeiro on Sept. 28….

Bless the child, at least she’s making an effort.

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2014 VMA, Artists.MTV, Music


What’s on the agenda as we start another week?