Another Perfectly Fine Idea

…shot to hell. At Forbes Sally Pipes reports on the results of implementing electronic health records (EHR), one of the provisions of the Affordable Care Act:

The EHR push started with the 2009 American Recovery and Reinvestment Act. President Obama approved billions in spending to encourage the healthcare industry to embrace the technology. Doctors and hospitals who failed to adopt a government-approved digital system by the end of 2014 faced cuts in their Medicare reimbursements.

So providers rushed to implement EHRs. Ninety-six percent of hospitals have EHR systems today, up from 9% in 2008. Most doctors adopted them as well.

But these EHRs ended up being seriously flawed—and dangerous for patients.

For one, patient records routinely have errors. In one survey, 21% of patients reported mistakes in their own electronic medical records. In some cases, when a physician pulls up a patient profile, the system displays a doctor’s note for a different patient.

Other issues abound. Systems are supposed to flag potentially dangerous drug orders but often fail to do so. Records frequently don’t list the correct start and stop dates for prescriptions. And transmitting data between systems is a huge challenge.

Consequently, the recent Fortune-KHN investigation revealed, “alarming reports of patient deaths, serious injuries and near misses—thousands of them—tied to software glitches, user errors and other flaws.”

More than 3,000 medication errors at pediatric hospitals from 2012 to 2017 were due in part to EHR problems, a study in Health Affairs found. About one in five of these could have caused patient harm.

A 2016 test simulation of hospital EHRs revealed that, in roughly four in ten cases, the system failed to detect potentially harmful drug orders. Of those, 13% could have been fatal errors.

I take a sort of perverse satisfaction in seeing that just about everything I have predicted about EHR has actually happened. Back in 2010 or 2011 I recounted the story of the presentation by an EHR vendor to one of my physician clients. At the conclusion of the horrifically arrogant presentation and after the vendor had left, I turned to my client and said “You were much more polite than I would have been. I would have thrown him out a half hour ago.”

Good systems and health care are not a congenial match. It is rare indeed that a system is designed following an industry-wide study of needs and practices. What is much more common is that systems will be what is easy to implement, what is fashionable, what a single client would pay the designers or implementers for, or whatever sticks against the wall. I haven’t look at EHR systems for a while but I would predict that today’s systems have all sorts of glossy claims about artificial intelligence, blockchain, and other buzzwords du jour.

I have looked casually at the systems being used by my wife’s health care providers and so far all of them have been ghastly. Any system in which the physician, PA, or nurse is tethered to a monitor and keyboard IMO is a failure.

Regardless, I think that EHR systems have tremendous, largely unrealized potential. It will take a while before it is realized.

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What’s That Got To Do With the Price of Gas?

There is a school of thought that all economic growth can be traced back to the price of gasoline. More broadly, that school would hold that the more energy that is produced, the greater the economic growth. Consider the chart above in that context.

That, too, is the context of this post at RealClearEnergy from Kathleen Hartnett White:

The economy is picking up steam. Fears of a recession have faded. Unemployment has hit a 50-year low, and it could go even lower. Wages are rising, and consumer confidence is sky-high.

Energy is driving all of those indicators. Cheap, abundant, concentrated energy fuels a manufacturing boom. Consumption of electricity has a direct correlation with economic growth. Our GDP, indeed, is rising at a brisk pace.

There is no inherent conflict between that view and strategies for a greener future. There is a conflict between that view and anti-development and BANANA strategies. Care should be taken to avoid conflating opposition to anything that might actually produce more energy with advocating strategies to use resources more efficiently, release fewer pollutants into the air, or decrease carbon dioxide emissions.

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Moving Down the Division of Labor

I agree with a lot of what’s in this piece at Founder’s Broadsheet but not this:

Populist nationalists in the Republican Party and socialists in the Democratic Party both believe that government should intervene to protect society’s members from the disruptive effects of economic development. They both believe that government can do a good job at this. Both share a delusive nostalgia for a bygone manufacturing era that cannot possibly return — as manufacturing becomes more capital-intensive and dependent on fewer but better educated workers.

[…]

We certainly need to thwart Chinese theft of US trade and defense secrets, but if China wants to take over and subsidize the production of our low-tech manufactures so our workers can move up in the division of labor, so much the better. It’s the Chinese theft of US trade secrets in advanced and military-related products that should concern us and their attempts to thwart the marketing of these products where our companies attempt to do so in China.

The emphasis is mine. It would be fine if that were happening but it isn’t and the author must surely know it. Just look at any monthly Bureau of Labor Statistics Employment Situation Report. Manufacturing jobs have been replace by service sector jobs requiring even lower skills and paying considerably less. I’d like to see his model of how that is good for most Americans.

The problem of our self-destructive relationship with China is not merely that the Chinese are capitalizing on our investments by letting us do the R&D, it’s that they’re using what they gain to force the U. S. economy into an dead end niche. We are a very diverse country and we need an equally diverse economy, one in which there’s room not only for professional and highly-skilled manufacturing workers but less-skilled workers, primary production, and agriculture.

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Comeuppance

At RealClearPolitics Charles Lipson warns that various law enforcement and intelligence officials are about to receive their comeuppance:

Over the next few months, we will learn the extent of that failure. We will see if top officials misused their agencies to investigate and crush their political opponents. Constitutional democracies cannot permit that. They cannot wave it off as yesterday’s news and expect to survive unscathed. If undetected and unpunished, it will happen again to another party, another candidate.

As the evidence comes out, a hard rain’s gonna fall. The damage will be compounded by partisan divisions, corroding trust in our basic institutions, and an impending election. For democracy’s sake, let’s hope the bitter winds are not a Cat-5 storm.

I don’t know. I’d be willing to bet a shiny new dime that not one of the worthies mentioned by Professor Lipson (James Comey, John Brennan, James Clapper, Loretta Lynch, and their senior aides) are ever convicted of anything. There’s already an iron-clad case for perjury against several of them and they haven’t even been indicted.

I’d also be willing to bet that all of their net worths are higher today than on the day they took office. Nice gig.

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Illinois’s Big Idea

Meanwhile, here in Illinois the Democrats in the state legislature have another big idea on which they can agree—that there is no limit to the amount of revenue that may be extracted from the taxpayers of the state of Illinois as this Sun-Times column from Mark Brown explains:

Sometime before the end of the coming week, the Illinois General Assembly is expected to approve a constitutional amendment allowing for a graduated state income tax, at long last putting the matter before voters in the 2020 general election.

What happens next is something most Illinois voters may have never seen: a chance to directly decide a major public policy issue by referendum, accompanied by the bruising campaign that goes with it.

I’m looking forward to the vote, having believed for some time that Illinois needs to scrap its flat tax, but dreading the campaign that will come first.

All the same mechanisms we are accustomed to seeing deployed in support of major political candidates — tons of television, digital and direct mail advertising — will be trained instead on an idea. The nuances of tax policy will be reduced to 15- and 30-second spots that further exploit our culture wars.

IMO Gov. Pritzker’s “Fair Tax” proposal is less workable in Illinois than it might be elsewhere for the simple reason that while the legislature may be able to raise the marginal tax rates on “the rich” they can’t force the actual rich to stay here. Note that those making $250,000 per year, the proposed threshold for those who will pay more taxes, include married couples consisting of a Chicago firefighter and a Chicago public high school teacher or the median physician. They will find it harder to leave Illinois than the top management of a big company will. Illinois is losing population faster than any other state in the Union and I suspect the “Fair Tax” will not slow that process.

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The Parties With Just Two Ideas

Have the two major political parties become parties with just two big ideas on which their members can agree? For Republicans those ideas are a) cutting taxes and b) opposing a sitting Democratic president. Needless to say Democrats have a similar resistance to presidents of the opposing party. This editorial from the Washington Post may give you some inkling of what the other idea is:

THE MOST enduring — and unforgivable — civil rights offense in our country today is the consigning of so many poor, often minority children to failing schools. Among the more promising efforts to deal with this urgent issue have been public charter schools, which give poor families the choice in their children’s education that more prosperous parents take for granted. That makes all the more distressing the bid by some Democrats to blame charter schools for all the ills of public education.

Sen. Bernie Sanders (I-Vt.), a candidate to become the Democratic presidential nominee, launched a broadside against charter schools, calling for a moratorium on federal funding for all charter schools and a ban on for-profit charters (which account for a small proportion of charters). “The proliferation of charter schools has disproportionately affected communities of color,” wrote Mr. Sanders as part of his 10-point education plan this month.

Mr. Sanders is right about the outsize effects on minority communities — but those effects have been positive, not negative. Of the nearly 3.2 million public charter school students, 68 percent are students of color, with 26 percent of them African Americans. Studies indicate that students of color, students from low-income families and English-language learners enrolled in public charter schools make greater academic progress than their peers in traditional schools. Research from Stanford University’s Center for Research on Education Outcomes found that African American students in charter schools gained an additional 59 days of learning in math and 44 days in reading per year compared with their traditional school counterparts.

Charter schools are not a replacement for traditional schools, and not all charter schools are good. Bad ones should not be tolerated. But blanket calls to curtail charter schools are wrongheaded. There is a reason that parents line up on waiting lists for coveted high-quality charter schools. Like wealthy parents who pay for private schooling or middle-class parents who move to neighborhoods for better schools, poor parents want a good education for their children. Without it, they know there will be diminished hope for upward mobility and a better future.

The politics of charter schools have always been fraught for Democrats because of the influence of teachers unions — which oppose charters for reasons having nothing to do with the welfare of children. We hope candidates keep in mind the polls that consistently show support for charters among black and Hispanic voters. It’s easy to oppose charters if you are well-off and live in a suburb with good schools. We hope we will also hear from candidates who know about the value of charters from their experiences — including as a mayor who used them to begin to turn around a failing district, as a partner in an administration that promoted charters, as a schools superintendent who made a place for charters.

George Santayana once quipped that a fanatic is someone who redoubles his efforts after having lost sight of his goals. It is not too much to say that Democrats’ support of public employees’ unions has become fanatical, to the actual detriment of the goals purportedly being sought.

We need to open a new can of political parties.

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The Energy of the Future

There’s an article about a nuclear fusion start-up at Forbes you might be interested in:

Walking with Michl Binderbauer into his 2-acre laboratory feels a bit like taking a factory tour with Willy Wonka. In one corner Binderbauer, chief executive of TAE Technologies, shows off a new machine that blasts cancer tumors with a neutron beam. Engineers huddle in a control room. Beyond their window: Norman.

That’s the name of TAE’s 100-foot-long prototype nuclear fusion reactor, a magnificent assemblage of stainless steel vessels, electromagnets and particle accelerator tubes. Once every eight minutes Norman emits a clang, as it transforms 100 million watts of electricity into a cloud of 30 million degree Celsius plasma that it blasts with beams of protons (the simplest form of hydrogen). They smash together with enough force to fuse into helium—releasing copious amounts of energy in the process. “It’s a function of violence,” says Binderbauer, 50, with a smile.

TAE, known until last year as Tri Alpha Energy, has raised $600 million, most recently at a valuation of more than $2 billion. Investors include the late Paul Allen’s Vulcan Capital, the Rockefeller family’s Venrock, and Big Sky Capital, family money of billionaire stock trader Charles Schwab. They’re betting that TAE will be able to tame fusion into a source of electricity.That’s the name of TAE’s 100-foot-long prototype nuclear fusion reactor, a magnificent assemblage of stainless steel vessels, electromagnets and particle accelerator tubes. Once every eight minutes Norman emits a clang, as it transforms 100 million watts of electricity into a cloud of 30 million degree Celsius plasma that it blasts with beams of protons (the simplest form of hydrogen). They smash together with enough force to fuse into helium—releasing copious amounts of energy in the process. “It’s a function of violence,” says Binderbauer, 50, with a smile.

TAE, known until last year as Tri Alpha Energy, has raised $600 million, most recently at a valuation of more than $2 billion. Investors include the late Paul Allen’s Vulcan Capital, the Rockefeller family’s Venrock, and Big Sky Capital, family money of billionaire stock trader Charles Schwab. They’re betting that TAE will be able to tame fusion into a source of electricity.

Nuclear fusion has been the energy source of the future since I was a kid. Back then they thought commercially-viable fusion was 15 years away. It still is. If they’re right this time, it will transform life on earth.

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Sabrina and Sabrina

Yesterday my wife and I watched Sabrina (1956) and Sabrina (1995) back to back. They are very different movies. All things considered I think the Billy Wilder-direct 1956 version starring Audrey Hepburn, Humphrey Bogart, and William Holden the better picture but the 1995 version starring Julia Ormond, Harrison Ford, and Greg Kinnear has much to recommend it, in particular Greg Kinnear’s charming performance as Sabrina’s obsession, David, Maude Larrabee played by Nancy Marchand, and the location shooting in Long Island, Paris, and Edgartown.

But Julia Ormond’s performance is not the star-making turn that Audrey Hepburn’s was in the 1956 version. And I’m glad that we have Humphrey Bogart’s performance on film just as I’m glad we have his performance, repeating his stage triumph, playing Duke Mantee in Petrified Forest. Linus is probably more like the real Humphrey Bogart, the child of privilege, than any of the heavies he played in the movies was. Or, indeed, as Rick was.

Neither of the two movie versions has the heft of their source material, Samuel Taylor’s Sabrina Fair, although to my eye the 1995 version takes more from it.

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Memorial Day, 2019

As I think I have mentioned before to the best of my knowledge none of my ancestors has died in war. Four of my great-great-grandfathers took part in the Civil War, on the Union side. None of them were killed although I believe that two, both of whom died young, had their lives cut short by the privations they experienced during the war.

The last member of my family to have fought in war has been dead now for 17 years. That was my mother’s uncle, Ed. He was one of the lucky few to be called up for World War II, Korea, and Vietnam. He was 97 when he died, a long and, I hope, happy life.

Neither I, my siblings, their spouses, their children, or their children’s spouses have ever served in the military. I was called up for Vietnam but was ultimately rejected for service. We have all depended on the sacrifices of others. Isn’t that what Memorial Day is about? Recalling our dependence on the sacrifices of others?

A number of my high school classmates lost their lives during the Vietnam War. I don’t know the precise number but it was not insignificant in a class of 215.

I do not recall ever hearing any of my nephews or nieces speak of never having served or the sacrifices of those who did. I hope they do not take their good fortune for granted.

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The Follow-Up Question

I just love sentences like this one from Bloomberg:

The first part of Inslee’s plan focuses on U.S. emissions, pledging to convert the country to 100% carbon-neutral electricity by 2030, and to mandate that all new buildings, cars and buses emit zero carbon.

Okay, let’s assume that starting in 2020 all cars emit zero carbon. When will the U. S. fleet emit zero carbon?

The answer is all other things being equal 2040 at the earliest. It takes at least 20 years for the U. S. passenger vehicle fleet to turn over.

There really aren’t many ZEVs (zero emission vehicles) sold in the United States. The entire boondoggle sounds like a backdoor subsidy to Tesla to me. I also wonder what the environmental impact of such a massive shift to fuel cells would be—a lot of those ZEVs will inevitably be powered by fuel cells.

I’d also like to see the net effect on emissions that would result from the mandate on buildings. It goes unmentioned in the article but producing cement is one of the largest sources of carbon emissions. Less than transportation or electricity but more than agriculture.

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