But it is fun and interesting to see how people adhere to certain segments of a two thousand year old document and completely and conveniently ignore other parts . A case in point is Deuteronomy 22:28-29, to wit,

“If a man happens to meet a virgin who is not pledged to be married and rapes her and they are discovered, he shall pay her father fifty shekelsof silver. He must marry the young woman, for he has violated her. He can never divorce her as long as he lives.”

Not only are you unlikely to ever see this biblical verse in numerical form under the eyes of Tim Tebow, but you are unlikely to see the GOP advocating for this biblical law as an inclusion to any state sexual crimes statues.

BUT,

Of course the same literalists will be opposed to a woman’s right to chose and a homosexual couple’s right to be protected by the same civil laws that apply to heterosexual couples based on . . . . . . biblical literalism because the Bible is supposed to be the word of God.

“The word”? It gets very interesting when you analyze the idiosyncrasies that arise in many verses. Deuteronomy 22:28-29 specifically states that a man should marry his rape victim and pay 50 shekels of silver only if they are discovered!

Seriously?

Correct me if I’m wrong but isn’t GOD, by definition, supposed to be all knowing? And if she is, then why include such a qualifying statement to an obvious rape-and-punishment edict? The answer should be that Deuteronomy was originally part of a basic local civil justice code for nomadic desert people from two thousand years ago that should not necessarily apply to modern life.

The next time that someone advocates against civil rights for same sex couples, ask them if they also would require that rapists marry their victims? Obviously only if they were discovered.

(Found per Reddit)

I’m not sure what was supposed to come out of his mouth. “Candidate”? “Proponent”? “Activist”?

Remember when then House majority leader, Representative Dick Armey of Texas referred to openly gay Representative Barney Frank as “Barney Fag” during a TV interview? Dick didn’t mean to say it. The phrase just came out. Obviously this desecration of Representative Frank’s name by turning it into a homophobic slur was commonly and frequently used by many conservative members of Congress and their staff in much the same way many people use derogatory and racial language to describe other groups of people while in private. Maybe Dick started using “Barney Fag” when discussing Mr. Frank so often that it became routine.  And then during the interview, it just . . came out. That’s a more plausible explanation than the statistically improbable likelihood that Dick’s brain randomly switched Mr. Frank’s last name for a derogatory term for homosexual that happened to start with the same last letter as his name.

According to Sigmund Freud, the tendency to inadvertently say things in an inappropriate context (i.e. a Freudian Slip) is caused by thoughts or beliefs from the subconscious that would normally be unacceptable to utter in public or mixed company. These beliefs are usually suppressed and come out at certain times when triggered. An example would be calling a woman by the name of your ex-wife just because she is very similar to her in appearance or mannerisms. But modern cognitive scientists believe (as I do) that these “slips of the tongue” are usually due to common prior and habitual language usage that inadvertently comes out in an inappropriate context, like a speech or interview.

Which raises the disturbing question. What did Santorum intend to say? Other then the obvious choice, there are not too many nouns that start with “nig . . ” and would make any sense when used in the context of the sentence, “the anti-war government . . . . . ” Nightwatchman perhaps? Like Mr. Armey, what are the odds that Mr. Santorum’s brain almost randomly inserted the worst of all possible slurrs to describe the President in the most inappropriate of contexts? Yea, not too likely. And so then one has to face the possibility that whatever was almost uttered is a habitual term used frequently by Mr. Santorum in private.

But maybe not. It’s far from completely certain that our once and future leaders are secretly racist, homophobic, scumbags. At least we don’t like to think so. Maybe the term that Mr. Santorum nearly uttered came from his belief that the President is really a member of the Knights who say “Ni” and as such the President is more concerned with acquiring inexpensive shrubbery in a two level pattern with a path running down the middle then with important things like the economy or comforting victims of Rush Limbaugh. It’s an entirely plausible explanation and I’m going to stick with it.

Is the President of the United States a member of this shrubbery loving sect?

]]> http://rangelmd.com/2012/03/open-mouth-insert-foot/feed/ 0 http://rangelmd.com/2012/03/how-would-a-facebook-medical-records-system-work/ http://rangelmd.com/2012/03/how-would-a-facebook-medical-records-system-work/#comments Mon, 26 Mar 2012 22:10:22 +0000 RangelMD http://rangelmd.com/?p=789 Last time I went over a few reasons why the current electronic medical records (EMR) industry continues to belch out software that is isolationist and proprietary.  Current EMRs don’t communicate with each other or much outside of the facility or health care system that they serve. Vendors and engineers have literally modeled EMRs to be an exact replacement for paper charts without taking advantage of modern technology beyond that of a fancy word processor.  It’s analogous to transportation technology 100 years ago. The first autos looked like carriages without the horses and very early attempts at flight usually involved a mechanism that flapped like a bird or some ridiculous outfit with wings and feathers.  Modern EMR design has advanced very little beyond being a hard drive replacement for the filing cabinet despite the fact that we have the capability to go well beyond the current technology.

So what does this have to do with Facebook? The important thing about Facebook is that it represents what can be done with “cloud computing” on a massive and efficient scale. Cloud computing means removing data from a local computer or data drive and moving it to a centralized location on the internet where it can be universally accessed. I.e. nobody has to go to a special library or coffee shop in order to access Facebook and nobody has Facebook downloaded and running on their home computer. All that one usually needs for cloud computing is a standard computer and an internet connection thus  minimizing up front costs while allowing simple access.

It is my belief that the current isolationist EMR system is too broken to be fixed in order to create a system where every EMR is capable of communicating with every other EMR. Literally thousands of separate software programs would have to undergo major and expensive revisions in order to meet universal communication standards. Even coming up with industry standards for communication between thousands of different systems would be a massive nightmare (and possibly one of the reasons why it was not addressed in The Health Information Technology for Economic and Clinical Health Act (HITECH) Act of 2009). It would be like trying to get everyone on the planet to agree to a common form of communication (besides soccer). It’s a near impossible task that has been tried in the past with almost zero success.

Instead, what is needed is the standardization of a common computer code or database language for the storage and organization of health care information much like HTML is the universal computer language for internet browsers. Once a standard database language is in place then different EMRs essentially become browsers.  Their selling points then become based on how effectively and clearly they present the information to the user plus whatever additional bells and whistles the user prefers.  And since the free flow of medical information should take priority then why not base these new EMRs on the best communication system ever invented; the internet? Freed of their proprietary shackles, it would no longer be important for electronic medical records to be stored in the physical location of any one practice or hospital. Providers would only need a computer (desktop, laptop, tablet, or smart phone) with an internet connection in order to access a patient’s universal chart from . . . . the “cloud”.

However, there should be several key differences between a social network and a universal electronic health records system. Unlike Facebook, a universal electronic health record (U-EHR) should not be centralized nor dependent upon any one company for development and storage in much the same way that HTML is an industry standard and no one company owns it or the internet. So who is going to store these U-EHRs? The short answer is anyone. Any company that has servers that meet industry standards for safety, efficiency, reliability, and security can store these records.  And who pays for this? Any number of business models can be developed. Like Facebook, servers can come with ads. Or different hospitals and providers can contract with different server companies to provide access to the U-EHR database in much the same way that they contract with an ISP to provide internet access.

Wait a minute. If different companies provide storage of U-EHRs then won’t each version of an individual record be different? Again, communication and flexibility are assets of this system. It should be possible for individual records to compare their current state with records on other servers and update itself if it finds a copy that is more current with recent documentation. This would be similar to how different Usenet servers currently update each other as new posts are added to any one server. This should be done behind the scenes and automatically. illogical conflicts between different copies (i.e. the patient being admitted to different hospitals on the same date) would be tagged to allow users to decide what is the correct or more pertinent information.  Ideally, each record would be like a Wikipedia entry with successive users constantly updating the information. Except that, like current EMRs, older entries and records (office visit notes, lab results, hospital admission records, etc.) would be locked after being electronically signed and changes to THOSE records will only be made with an addendum note.

Such a cloud system has the possibility of allowing for “push” technology for updating U-EHRs. Push technology means actively forwarding information to an application without that application having to call for it (pull) such as sending you email without you having to check it. The push in the case of a U-EHR system would actually be from user to server. Once a new document is entered or changed in the U-EHR that change is communicated or pushed to all known EMR servers and copies of the record. Again, this would be done behind the scenes as different servers receive this new information and records check each other for accuracy.

Such a paradigm shift in how we store and retrieve health care information is going to have a lot of people crying heresy. The idea of decentralizing health care information is going to be alien and threatening to many people. Even though many EMRs currently have the capability for remote access to records over the internet from home or office, many providers are going to oppose such a system because they will feel a loss of control over the records of their patients. They will claim that cloud storage and retrieval of records is not secure or reliable. What happens if the server crashes and it loses all my patient’s records? What happens if the system is hacked and all the records are stolen? What happens if my internet connection goes down? All of these are valid concerns but not absolute contraindications to a cloud based electronic medical records system.

There is no reason to believe that medical information stored in a cloud system would be any less secure than a pile of paper charts crammed into the back closet of an office or an obsolete server running an EMR in a poorly ventilated space.  A single theft, fire, flood, or hard drive failure can take down an entire office EMR but a decentralized U-EHR system would be largely impervious to the destruction of any one server in the highly unlikely event that total disaster ever occurred. And the likelihood of losing your internet connection is about as likely as losing your electricity. The few areas of the country that lack reliable internet access will likely match those areas that lack electricity within a few years.

Security is a bigger concern. Placing very sensitive information on the internet makes this information potentially accessible to anyone on the planet with a computer and a connection. Then again, any EMR with an outside connection for remote access is theoretically vulnerable to attack and professional internet storage providers tend to have far more sophisticated security than Dr. So-and-So running his EMR on a Windows Me server under his desk.  I would think that the loss of one’s bank account would be more of a concern than the loss of one’s medical records but this has not stopped millions of Americans from converting to online banking. In my view, the benefits of online health information far exceeds the risks.

The concerns of individual providers however, will pale in comparison to how much resistance to a cloud system will come from the larger health care industry and EMR vendors in particular. In theory, EMR clients accessing cloud based medical records would be far less expensive (if not free) than current EMR systems which can cost tens of thousands for individual practices or tens of millions for hospital based systems. And incompatible older EMRs will have to be completely redone or scrapped. If your giant hospital conglomerate just spent millions on an old style isolationist EMR just to capture some of the bounty earmarked in the HITECH act, there is going to be a lot of complaining.

Sadly, a universal electronic health records system will not work without substantial participation by the vast majority of health care providers, health care facilities, laboratories, pharmacies, and imaging facilities to ensure that the records are accurate and up to date. The Centers for Medicare and Medicaid Services (CMS) has the power to impose mandates (usually unfunded) and can require all providers and facilities that accept Medicare or Medicaid to participate in such a U-EHR system. But they won’t. CMS would rather mess around with pointless and unproven quality initiatives (read: additional pointless paperwork) than do something that has a significant potential to improve health care safety and quality.

What the internet looked like in the '80s and what electronic medical records look like today.

The Internet beta 0.5 version was nothing like it is today.  Back in the ’80s and the early ’90s the most common way to access the outside world was to use a phone modem to dial the number of a remote computer. These primitive servers usually ran DOS based software called a Bulletin Board System (BBS) which allowed users to post messages to each other. For the most part, these servers were isolated and did not communicate directly with each other. If you wanted to connect to a different BBS you literally had to hang up on one and call another one. There were usually no centralized servers that could link and share information among multiple BBSs. This sharing of information among multiple interconnected computers, servers, and networks is essentially what the modern internet is and once the world wide web started to proliferate in the mid to late ’90s the old BBSs became extinct. Facebook is a perfect example of modern Internet use. It’s essentially a vast central database with millions of users who can easily access information using multiple devices, upload and download data in multiple formats (text, links, pictures, video) from multiple sources and all from a single internet connection.

It sounds like Facebook would make a great starting template for a vast interconnected medical records system. But the reality is that the electronic medical record (EMR) industry is still stuck in the era of the BBS.

The similarities between modern EMRs and the BBS system are striking. Like many old Bulletin Board Systems the vast majority of EMR systems do not communicate with each other (nor even the outside world). Not only are they often incapable of communicating with another EMR or computer but even in 2012 most new EMRs don’t even have an option for sharing information with other systems! This is one of the biggest paradoxes and failures of almost all EMRs. Designed for an industry where the sharing of medical information among different facilities and health care providers is critical to the timely, effective, and safe delivery of medical care, the majority of these systems are designed to share information only within the limited confines of the specific facility or health care system that they serve. EMRs are essentially information islands cut off almost completely from direct contact with the rest of the interconnected world.

The system at the hospital where I work is a perfect example of this isolationist mentality.  In its current form, the hospital EMR cannot send or receive information from doctor’s offices, labs, or imaging centers outside of the actual facility. Acquiring old documentation still requires one or more phone calls, several human intermediates, a fax machine (40 year old technology) and open business hours (no luck if after office hours, on weekends, or holidays). Even worse is that the system can’t even communicate with older electronic systems within the same facility and has no capability to input and store faxes or scans in a format such as PDF for internal viewing. This means that we are still stuck with a hybrid EMR-paper chart system that is often more cumbersome and inefficient than using either system alone.

And how did it get to this pathetic point where a guy in rural Brazil can upload a picture of his strange rash to someone in China in real time but I can’t get critical medical information on a patient found unconscious until their doctor’s office opens the next business day? Given all of the concern about online privacy and hacked Facebook accounts you might think that the health care industry is cautiously avoiding systems where private information could be compromised (never mind that there has not been a massive collapse of the credit markets from widespread identity theft and fraud from 100s of million of Facebook users). The motivation of the health care industry in avoiding interconnected medical record systems is not to protect patients but rather, to protect itself.

Specifically, they want to protect themselves from competition. The majority of health care facilities and health care providers still think about medical records the same way they did 100 years ago – as property or proprietary information. A physical medical chart is considered to be the property of the facility or provider who generated the chart even though the patient is considered to be the “owner” of the information contained within the chart. A Paper chart is usually stored at the same facility where it was created and patients often prefer to return to the same facility or provider if for no other reason then because “that’s where my records are.” Changing facilities or providers can often be a problem for patients who must go through the bureaucratic hassles of making a formal request for their records and then having to pick them up and hand-deliver them to a new office or provider. This system is effectively a disincentive for patients who wish to change providers or health care facilities and is, ironically, a barrier to the sharing of information.

Not surprisingly, the electronic version of the medical record system continues this same isolationist mentality. Even though digital information replaces paper folders and charts, electronic records are usually restricted to the system that generated them. Most EMRs are designed to be run on a server or computer that physically exists within the same office or facility and without any direct connection to the outside world. The only way to share information is the old fashioned way – i.e. the electronic record must be printed out and either faxed or hand-delivered to another office or facility. In this way, most EMRs are little more than a hard drive replacing a filing cabinet. But wait, that’s not all. Most EMRs are themselves proprietary software. Most of the expensive systems in particular are not compatible with transferring information to other EMRs without extensive and expensive modifications. If all EMRs could communicate with each other equally then providers would just purchase the cheapest ones thus damaging the finances of the industry. Right?

Wrong. Business is ripe with examples where standardization and compatibility among different products has lead to expanded market size and share even among competitors. The electronics industry is just one example. Another example is the Internet and web browsers. If Internet Explorer were only able to access web sites running Windows server software, then the massive growth and success of the Internet would have been severely blunted. Instead, the industry got together and decided on a common language (HTML) that is usable by any browser. Obviously industry standards can be voluntary or by government mandate. So the question is; why not make all EMRs capable of communicating and sharing information with each other? The Federal government recently had the chance to do so and severely blew it.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided financial incentives for early adopters of electronic health records and even provided definitions of “meaningful use” and what information an EMR should be able to record and store. But the single biggest failure of HITECH was that it did not define standards of compatibility nor even require compatibility among any of the thousands of different electronic medical record systems. Hundreds of millions if not billions of tax dollars will now go towards further entrenchment of the current isolationist proprietary EMR industry.  And this is not good for patients or consumers either. In theory, if all electronic medical records were freely and easily transferable among different providers and facilities, the artificial barriers for patients to changing providers and facilities wound be gone and providers and facilities would have to compete based solely on the quality and efficiency of their services rather then relying on holding medical records hostage in order to generate return business.

However, improved competition among health care providers is not the primary aim of open and efficient transfer of health related information. Accurate and up to date health care records that are easily and universally accessible have the potential to improve the safety, quality, and efficiency of health care delivery. Costs can be decreased by reducing the need for repeat labs and tests. Older patients in particular would benefit from accurate medication lists and lists of prior drug reactions and allergies to reduce the possibility that providers will prescribe medications that could interact with a patient’s other medications or be contraindicated for any one of their medical conditions.  Ensuring that open and free communication of medical information exists between EMRs appears to be beyond the scope of the current records industry. This is something that only the Federal government will be able to do when and if it decides to get serious about modernizing health informatics.

Or claim that I’ve actually seen a Leprechaun (not verifiable).

Opposes a state mandated HPV vaccine (medically critical to the prevention of cervical cancer) for Texas school children because it will lead to more underage sexual activity. Yup, conservatives were furious at Texas Governor Rick Perry for signing the executive order requiring the HPV vaccine that has the potential to save thousands from cervical cancer. Rep. Michele Bachmann (R-Minn.) called it a “government injection” of a “potentially dangerous drug.” And there is no proof that vaccines lead to increased sexual activity in school children.

And, just to make sure they are inconsistent and morally bankrupt, Texas Conservatives . . . . .

Passed a state law mandating an invasive vaginal ultrasound (a non-medically indicated test) for Texas women seeking a legal abortion because it will lead them to cancel the procedure. Yup, not one conservative has yet called this procedure a “government penetration” nor has anyone come up with a rational argument for the mandating of this procedure . . . . other than the obvious: it’s a deterrent to try and shame women into avoiding an abortion even though there is no evidence that this works.

But, not to leave out the other side of the aisle.

The inconsistent Liberal:

Believes that outlawing marijuana drives legitimate business underground, leads to increased criminal activity, and does not deter use. Wants marijuana legalized.

Believes that outlawing corporate campaign contributions won’t lead to increased illegal campaign financing and does reduce special interest influence on the political process. Wants campaign finance reform.

Usually, alprazolam is prescribed as a short term treatment of acute anxiety disorders. It is classified in the US as a controlled substance with significant abuse and addictive potential. It’s popularity may be due in part because it is widely considered to be relatively mild and safe by many patients and their physicians. But, in fact, alprazolam can be much more toxic than even other prescription sedatives.

However, unintentional overdose with alprazolam alone is unusual (it was responsible for less than a quarter of ER visits  for benzodiazepine toxicity in the US for 2008). What is much more common is unintentional overdoses that involve other prescription medication and/or alcohol. It’s unclear why but it may be that patients are unaware of or tend to minimize the risks of combining different controlled medications that could suppress breathing. Or they don’t realize that alcohol can suppress breathing, be difficult to dose (because you are already intoxicated), and have an additive effect when combined with benzodiazepines.

What I want to know is . . . . who is the physician . . . .  being aware of Mrs. Houston’s very well publicized problems with substance abuse, including cocaine and alcohol . . that he or she felt compelled to write her a prescription for alprazolam or other sedatives which she then reportedly filled at a local pharmacy? It would have been understandable if the late Mrs Houston had diverted another person’s medications for her own use or acquired sedatives over the internet or in another country or illegally on the “street” but from all accounts she was actually legally prescribed these medications by an American physician!

Strictly speaking, a history of alcohol or other type of substance abuse is not a legal or medical contraindication to prescribing controlled medications for a medically valid reason. But, there has to be a good degree of due diligence and caution on the part of the prescribing physician in these cases.  Drug testing can be done on potential candidates for therapy with sedatives and a detailed and complete history of the patient’s prior problems with substance about should be performed in order to allow the physician to get the best possible idea of the patient’s tendencies and potential for abuse. Treatments for pain, anxiety, and insomnia should start with non-controlled medications and drugs with the lowest potential for harm and abuse before stepping up to more powerful alternatives. In the very least, small amounts of potentially harmful medications should be prescribed in a “trial” treatment period to be used sparingly and only as a last resort.

But this approach is often an idealistic fantasy when confronted with the reality of real-world medical practice. Patients can be demanding and incredibly impatient and the physician has only 15 minutes (often less) to gather as much information as possible and develop a complex treatment plan. Too frequently this process gets degraded into the best plan for getting the patient in and out of the office in the shortest amount of time and this often includes a month’s supply of the desired medication and a cursory warning of the risks.

But even without these time constraints, the fact that the patient is a major celebrity can have significant and deleterious effects on clinical decision making. This was clearly seen when Dr. Murry felt compelled to discard sound medical judgement when he delivered a powerful anesthetic to Michael Jackson to treat insomnia. Maybe this is what happened in the case of Mrs. Houston? How can you say “no” to a famous patient?  The temptation to give in to the needs of a super-famous client might have been too much for the local MD.

Still . . . . . this justifies nothing.

Americans invented the idea of  “McDonaldization” in which consumer services are standardized to be efficient, predictable, and controllable.  When we want something, we want it now!  We want to be able to understand it, predict it, and control it.  However, healthcare isn’t a service that’s amendable to McDonaldization.  Cooking and serving up fast food has a relative small number of variables that can easily be controlled and predicted such as the size of the hamburger patty and the heat and time required to cook it. The diagnosis and treatment of human illness has literally hundreds of millions of variables to deal with. This is why medical care is not anywhere near as “convenient” as fast food.

But the folks at X-prize want to change this.  Their solution is to open a competition for inventors to develop a Star Trek style “tricorder” to detect and diagnose disease just as the fictional medical tricorder was used in the science fiction series. What is the specific problem to their tricorder solution? According to their promotional video, consumers are faced with a paradox.  From the video;

You want to know what’s wrong. Is this normal?  Is this urgent?  Do I need to see a doctor? But, today, the only way to know if you need to see a doctor is . . . to see a doctor. And that’s not fast, not convenient, not easy. So you wait . . .

The average time to get an appointment is 21 days. The average visit to the doctor takes nearly 2 hours.  Cause you’ve got nothing better to do, right? And then you only receive the right diagnosis or treatment 55% of the time.

Correct. Medical care is nether efficient, convenient, predictable, or controllable and this drives Americans crazy. Part of the reason is the massive complexity of human disease. Part of the reason is how our health care system is organized with way too much emphasis on advanced medical care and procedures and too little emphasis on health care access, primary care, and prevention.

The X-prize foundation’s approach to this problem is to empower consumers and patients with a quick and easy home or outpatient mobile  device to provide real time data on critical health metrics such as vital signs to accurately diagnose disease.  The requirements appear to be only that the device is mobile and be able to accurately diagnose a set of 15 diseases. There is no information on what these “diseases” would be.  The device should also be able to give information to the patient as to whether everything is “OK” or not.

The push to develop a more patient friendly health monitoring device is certainly laudable.  However, it’s not likely that such a device will work in the way that they intend it to. The problem won’t necessarily be with limitations in technology. The problem will be in how we interpret and act on information. The limitations and complexities of the diagnostic and treatment process is something that doctors have to deal with every day. Doctors take a limited set of data and formulate what they believe is the best diagnostic and therapeutic course of action that is uniquely tailored to each patient and each  situation.  They take into account not only the data but their training, experiences, statistical probabilities, and “educated guessing”. This is why medicine is still an art.

And data is not the end point of the diagnostic process. Each abnormal data point could have multiple meanings depending on what you are looking for (the pre-test probability) and the statistical likelihood of disease in your particular population. For example, an elevated blood pressure could mean that you have hypertension or it could mean that you are anxious or because of medications or because of renal artery stenosis. A high heart rate could mean anxiety or a pulmonary embolism. Abnormal laboratory results have the same problem. A low sodium level could be caused by anxiety or a brain tumor. Anemia could be caused by a poor diet or colon cancer. Even imaging is tricky. A mass seen on an XRay or CAT scan could be benign or malignant. There is even the fixed and known possibility of false positives and false negatives for each test that has nothing to do with error or technical variability. Detecting abnormalities is easy. It’s the interpretation that is hard. To say with confidence that your device will be able to diagnose a specific disease with “accuracy” is dangerous thinking.

And who or what will interpret the data for the tricorder user? A computer algorithm can be used but is likely to come up with a diagnostic differential list that may not be accurate and will certainly not be exhaustive. This is because the initial evaluation of a patient is often followed up by more advanced evaluation and it is currently not possible to put every diagnostic modality (Xray, CT scan, PET scan, nuclear imaging, EKG, EEG, biopsy, stress testing, and exploratory surgery) into a mobile phone. Maybe in the far future we will develop a “universal” diagnostic device that includes everything but this is not one of the stated goals of this X-prize.

Even worse than diagnostic uncertainty is the false sense of security that could be provided by normal data in the setting or real disease (i.e. a false negative). The FAQ page from the X-prize foundation states that the tricorder should be able to “give confirmation that everything is ok with a consumer and notify that something is not ok (a “check engine light”)“. This approach is simplistic and absurd to the extreme. Show me a person with completely normal vital signs and blood tests and I’ll show you a patient who is has undiagnosed HIV or a smoker who has a malignant growth in their lung. The danger is that whatever limited data this device does provide will, if normal, give consumers a false sense of security and lead them to cancel that trip to the doctor.

The biggest problem is that such a device is either not required for it’s intended purpose or won’t make any difference in outcomes. Will it really be able to help people make a decision on whether or not to see a doctor or go to an ER? True medical emergencies almost never present subtlety. Ironically, PAIN is one of the biggest indicators that something is seriously wrong and the measurement of pain is not something that can currently be directly done by a tricorder or any other device.  Bleeding, passing out, shortness of breath, vomiting, decreased consciousness; patients rarely have a problem knowing when something is seriously wrong because their bodies do a much better job than any tricorder could do in letting them know. And when should you go to see a doctor in an non-emergent setting? The best way is to use a simple rule of thumb. If you have to consider it then likely you should go. And as far as prevention, do we really need a device to tell us to stop smoking, loose weight, and get some exercise?

There yet may be some uses for such a device. More frequent monitoring of metrics like blood pressure and blood glucose levels in the outpatient setting may, if accurate, help doctors to better control such chronic conditions as hypertension and diabetes and better control can lead to better outcomes. Cheaper and mobile medical devices would help health care workers enormously in areas of the world that are remote and/or lack access to modern medical care.

But to develop a device with the stated goal of “empowering” consumers in their health care decisions by helping them know when they can avoid the inconvenience of having to see a doctor is amazingly shortsighted and ridiculous. And it’s potentially dangerous by giving people a false sense of security that they do not need to see a doctor.

I foresee one main outcome of the development of this tricorder. The typical civilian users of such a device are likely to be suburban, middle aged, relatively healthy and health obsessed. These are the types of patients that doctors in affluent areas dread. These patients Google the differential diagnosis for every single symptom or strange noise coming from their bodies and make frequent trips to their doctor with pages of printouts about their “condition”.  Congratulations X-prize! You’ve begun the process to develop the most important enabler for hypochondriacs that the world has ever known.

Once upon a time, video pirates were limited to taping movies off cable and selling the tapes to their friends. But this didn’t put a dent in Hollywood’s ability to make and profit enormously from crappy movies. Then came the internet (or the internets for those of you in Texas) and people could easily share digitized copies of music and more crappy movies. Then came the Digital Millennium Copyright Act of 1998 (DMCA) that brought copyright protection into the digital domain to outlaw the intentional sharing of copyrighted material.  But the problem with the DMCA was that it was ineffective outside of US court jurisdiction.  Other than war, how does a greedy media mogul prevent foreign internet sites from providing illegal downloads to Americans? Answer; make US internet service providers (ISPs) liable and responsible for blocking access to these illegal sites. Enter the Stop Online Piracy Act.

The SOPA would allow media companies (or any owner of copyrighted material) to ask the US Attorney General to demand that American ISPs directly block access to any foreign web site that is believed to be violating US copyright law. But that’s not all! The bill allows the Justice Department to seek to prevent internet search engines (Google, Bing) from listing the offending site and stop US internet advertizing companies and internet pay services like PayPal from doing business with the offending site. Additionally, internet companies  that take the initiative and block access to a foreign web site that they believe violates US copyright law would be immune from litigation. Much has been written about this pile of dung pending legislation but I would like to add a few NON-lawyer observations.

1. SOPA appears to circumvent the 5th and 14th Amendment guarantees of Due Process. All it takes for the US AG to order a web site blocked is to obtain a court order. The order remains in effect indefinitely. There does not appear to be any provisions in the act to  allow for a hearing or trial to give the offending site and/or the ISP a chance to present their case even if the “foreign” site is owned by a US company.
2. The lack of Due Process makes it more likely that SOPA could be used to restrict free speech by a person or organization seeking to abuse the law.
3. Lack of Due Process misplaces the burden of proof. Any involved party can  petition the court to overturn the order but since the initial order remains in effect indefinitely the burden of proof is placed on the accused (the ISP or other domestic internet company).  This is exactly the opposite of our innocent until proven (by the government)  guilty legal traditions.
4. SOPA is a huge departure from current law that limits the liability of  Internet Service Providers for the activities of their customers. Under DMCA, providers are liable for copyright law violations only if they directly participate  in or directly benefit from illegal activity.  Simply providing internet access that MIGHT be used to download pirated music is not in itself illegal. This is consistent with existing law that does not require telecommunication companies to verify that their products are being used only for legal purposes.
5. SOPA places the burden of monitoring and preventing international digital copyright violations on the internet service providers instead of with law enforcement and foreign governments.  Cell phone companies are not required to monitor nor guarantee that pre-paid cell phone are being used for family friendly activities.  Lawmakers need to learn to differentiate between the illegal act and the medium that made such an act possible.
6. Immunity from litigation for blocking web sites is a legal mess waiting to happen.  What is to prevent a US internet service provider from blocking a “foreign” web site that is actually owned by a US company and direct competitor of the ISP in question? Does Congress really want to dole out liability protection and the power to block web sites to ISPs?
7. SOPA does not make any exceptions for non-profit sites, archives, educational sites, etc.
8. SOPA will not be effective if utilized as intended. Piracy sites and services are notorious for finding technical ways around censorship. The technology neophytes who wrote this legislation seem to be blissfully unaware of the dynamic nature of the internet. Pirate web sites are not like illegal bordellos that can be raided and shut down.  New DNS addresses and servers can be set up and the new address disseminated online via social networks in a fraction of the time it takes for a court to issue an order.  A more likely scenario is for a game of “cat and mouse” to be played out over weeks to months as pirate sites stay several steps ahead of the Justice Department.
9. A SOPA that does not work as intended could lead to an actual American firewall. If trying to block access to individual addresses only leads a futile cat and mouse chase across the internet, the Justice Department may decide to broaden its court order to the blocking of entire foreign ISPs, networks, or even entire countries. This is not a slippery slope. This is a realistic technical solution and logical end-point for a law that aims to prevent the illegal sharing of copyrighted material. There is nothing in SOPA to prevent this from happening.
10. Is SOPA really needed? There is no hard evidence that illegal file sharing has had any large or lasting impact on the legal sales of nor the production of  intellectual material. If the Justice Department were able to successfully block every single global illegal file sharing site, would it really result in any significant additional revenue for the entertainment industry? Is it worth the potential chaos, abuse, and damage to the freedom of the internet just to secure a few million more in income for an entertainment industry that is in no danger of becoming extinct anytime soon?

Congresses’ repeated attempts to focus more attention on preventing illegal downloads of such American classics as Freddy Got Fingered than they do in passing laws to prevent internet censorship and guarantee internet access is more than a clear indication that our representatives are by-and-large older white men who don’t known how to use a computer, think that the internet is literally a system of tubes, believe that freedom and commerce can be protected by restricting it, and frequently get calls and visits from a nice gentleman who works for the MPAA or the RIAA and would like to treat them to a little lunch or a round of golf in Tahiti.

Please write your Congress-person or Senator. Also, let the sponsor of SOPA, Rep. Lamar Smith (R-TX), know what you think of him and his bill.

It’s stunning to think about the national debt in these terms.  What’s even more stunning is how brazenly both parties, liberals, and conservatives are willing to risk long term economic security to feed their own ideological interests.  A case in point is the NYT’s Paul Krugman who dismisses any short or long term concerns about the US debt with a fanciful wave of his a priori wand. What is Dr. Krugman’s calming tonic in the face of a 15 Trillion dollar IOU? Basically, he implies that the debt doesn’t matter as long as you can raise taxes and interest rates remain low.

Deficit-worriers portray a future in which we’re impoverished by the need to pay back money we’ve been borrowing. They see America as being like a family that took out too large a mortgage, and will have a hard time making the monthly payments . .

First, families have to pay back their debt. Governments don’t — all they need to do is ensure that debt grows more slowly than their tax base. The debt from World War II was never repaid; it just became increasingly irrelevant as the U.S. economy grew, and with it the income subject to taxation.

So as long as we have rich Americans from which the US government can feed from then we will be OK. After all, the top 5% of income earners pay 60% of the US income tax even though their income is 35% of all personal income. For liberals, as long as we can raise taxes, we can continue deficit spending ad nauseum.  For conservatives, it’s even worse. The mantra appears to be deficit spending with low taxes now (trickle down) and to hell with the future.

Of course, Krugman is correct . . . .  about the present. The enormous US debt does not pose a serious short term threat to the stability of the US economy or economic recovery.  Given the sheer size of the US economy, there is no credible risk that the US government would default on it’s debt nor is there any reason to believe that the market for US Treasury bonds would dry up or become unstable. And interest rates are at an all time low, thanks mostly to the severity of the recent recession and the efforts of the Federal Reserve to stimulate the economy through borrowing and investment.

But, like the sky diver falling without a parachute, the danger for the US economy lies not in the present while tumbling through space but at some point in the future when the ground makes its presence known. It’s inevitable that the economy will pick up steam and with growth will come a rise in interest rates. Even small increases in rates can have a profound impact on the interest we pay on the debt.  Right now the interest payment on the national debt is about $242 billion a year.  Interest rate increases over the next decade have the capability of causing the interest on the national debt to exceed $1 TRILLION a year! Chew on this number for a while. This amount represents mandatory spending that does not go towards any social program, military asset, or regulatory agency. These billions pay investors in the US debt of which almost 50% are now foreigners (mostly the central banks of China, Japan, the United Kingdom and Brazil).

There is a very real possibility of a spiraling and out of control situation to develop as the interest on the national debt becomes bigger. Growing entitlement programs (Social Security, Medicare, Medicaid) combined with the increased interest payments could cause mandatory spending to exceed total government revenue. At this point the government’s ability to manage the debt would become even more difficult from a budgetary and political standpoint. The remaining choices, massive cuts in discretionary spending (including defense), massive cuts in entitlement benefits, and/or massive tax increases would become ever more drastic and unpopular.  Just like today there would be government gridlock, indecision, and political pettiness all resulting in  action that will be too little, too late. Meanwhile, the spiral continues, with increased budget deficits creating an ever larger national debt with increased interest payments

What happens then? The problem is that nobody really knows, not even Dr. Krugman. There is a great amount of debate among economists about how big the national debt burden could become and when the economy would become negatively affected. There is evidence that among industrialized countries, those with national debt below 60% of GDP had better annual economic growth (3-4%) than those with debts of 90% or more of GDP (1.6%). Though it’s unclear whether the larger debts were due to a slower economy and a decrease in tax revenues, the possibility remains for a negative impact on economic growth. Krugman further tries to differentiate debt held by households from the national debt.

This is the point almost nobody seems to get — an over-borrowed family owes money to someone else; U.S. debt is, to a large extent, money we owe to ourselves.

No it’s not.  As mentioned, almost 50% of our debt is held by foreign banks. And we can’t just stop paying interest on the debt because it’s “money that we owe ourselves.”  A US default on its debt or even a perceived inability of the US government to pay interest on the debt would result in volatility in the bond market causing falling bond prices and increased interest rates which would worsen the budget crunch as previously stated.  The US government is very much like a household that is very overextended on its credit. It’s like a family taking advantage of a credit card with no limit and ridiculously low interest rates.  A default would wreck the world wide economy and impair the government’s ability to borrow more money at low interest rates.

But lets assume that Krugman is correct and we can go on borrowing forever because it’s money that we owe ourselves that we don’t have to pay back. The problem with this “all is well” approach is it does not take into account the possibility of a “perfect storm” of different economic factors combining with our debt burden to result in economic catastrophe. Greece is a good example. They were forced by the Economic Union to adopt the Euro at inflated exchange rates for the old drachma that severely impaired their ability to borrow and service their national debt.  Though the US does not face the same type of monetary problems, the recent collapse of the sub-prime lending market is a good example of an entirely new economic variable that was unforeseen by almost every economist.  Hence, like earthquakes, economic disasters are very hard to predict but inevitable. The US national debt is like the proverbial sword of Damocles hanging over our heads. It has the potential to dramatically worsen and complicate what would normally be a survivable economic crisis.

Above all, however, Krugman and everybody else want job growth combined with economic growth. The problem is that the current massive amount of government spending is poorly designed to deliver this.   John Maynard Keynes famously called for the government to “prime the pump” with government spending for goods and services to stimulate the economy but the 2011 Federal budget included over $2 Trillion in mandatory spending and most of it was spent -quite literally – on people who are NOT WORKING. Social security for retirees and people with disabilities. Medicare for people older than the traditional retirement age of 65. Medicaid much of which is for children and those on disability. Unemployment benefits for . . . . people who are unemployed! And the recent bank bailouts designed to keep bank employees who already have jobs from becoming unemployed.  Even recent massive spending on two wars was primarily spent overseas during the occupations to employ Iraqis, Afghanis, and other foreigners. In theory and except for Federal employees, US government spending does not result in the creation of a single new American job.  It helps to maintain the status quo. No wonder the recovery has been jobless and sluggish.

During World War II the US government spent several hundred billion dollars to directly employ Americans to provide goods and services for the war effort. The economy responded with the biggest peacetime expansion in history. But today we have a multi-Trillion dollar economy and a few hundred billion dollars in domestic spending here and there is not going to cut it. What is needed is a multi-Trillion dollar domestic spending bill for the direct employment of Americans for nationwide infrastructure improvements. Unfortunately, we’ve already used up our political capital with year after year of massive deficit spending regardless of crisis. At least World War II had an end. By 1946 we no longer needed thousands of tanks, planes, and ships to fight the fascist threat and so spending decreased dramatically to prewar levels. This fiscal rationality no longer applies. For three decades, nearly every Federal budget has been followed by an even bigger budget. We no longer have either the political foresight or will to constrain spending so that we can reserve massive spending increases for times of true emergencies.  We have been spending our “rainy day money” on sunny days and now we have nothing left.