EMR in a hurry: snafu ahead

Obama proposes a fast start on electronic medical records within the stimulus package, a bad idea. A case study from England on spine records.

Barack Obama has invited Paul Krugman to come up with better ideas for the stimulus package. Can anybody play? None of us ‘umble bloggers here has a Nobel, Fields or – much the best money – a godly Templeton. But between us we have already come up not only with an early broad list of initiatives but with nifty specific ideas for a few billions in instant spending:

* designer pylons for the interstate electricity grid that don’t make you think immediately of the Welsh for Semtex – these can be ordered in advance of fixing the routes

* 100 million cat’s eyes for safer roads (bonus feature: very labour-intensive to instal)

* best of all, Jonathan’s proposal for a malaria eradication campaign.

Obama’s planned stimulus package includes the electricity grid and road upgrades so we may be partly in luck. However one plan the transition does have is premature. They have not been playing close enough attention on how to fulfil Obama’s campaign promise for electronic medical records (here, here, and here).

From Obama’s Fairfax speech on 8 January – even the URL is on message – my italics:

To improve the quality of our health care while lowering its cost, we will make the immediate investments necessary to ensure that within five years, all of America’s medical records are computerized.

Er, what immediate investments? FWIW, I did suggest that two pieces can reasonably be started right away: a secure e-mail network (VPN) for American health care workers, and regional data warehouses for the results of X-rays and other scans. The data warehouses don’t depend much on the rest of the system; scan files only come in a limited number of formats, and scans are so expensive that writing conversion filters will generally be worthwhile.

But the main course is the actual detailed records of care. Here subsidising doctors and hospitals to rush out and buy lots of incompatible state-of-the-art kit is a bad idea. It’s roughly what happened in England in the 1990s, and they had to start all over again. Down the road you will have to spend even more to put it all together. You have to think out first what you are trying to achieve: a coordinated national EMR network that balances privacy with efficient care. And you have to get the medical practitioners on board, not just IT firms, management gurus and consultants. (Remember Ira Magaziner?)

Let’s walk through a small example from the English NHS project.

Continue reading “EMR in a hurry: snafu ahead”

The Jimmy Durante Stimulus: Let’s Eradicate Malaria

Want an easy, politically powerful, and incredibly effective stimulus initiative? How about eradicating malaria?

Now that, as the Schnozzola himself would say, everybody wants to get into the act, here’s a proposal for the stimulus that would have an enormous impact: fight malaria.

Malaria? Don’t we already know how to get rid of that? Yes: that’s what makes this such a travesty.

Malaria still afflicts 3 million Africans a year, and of particular importance, it destroys economic productivity because it causes so much loss of work and human capital development. The disease kills an African child every 30 seconds. Malaria eradication is a crucial element of the United Nations Millenium Development Goals for precisely this reason: you simply can’t make a dent in extreme poverty without making a very big dent in malaria. As the Earth Institute explains:

Malaria and poverty are intimately connected. Judged as both a root cause and a consequence of poverty, malaria is most intractable for the poorest countries in the world. Malaria affects the health and economic growth of nations and individuals alike and is costing Africa about $12 billion a year in economic output.

Annual economic growth in countries with high malaria transmission has historically been lower than in countries without malaria. Almost all the rich countries are outside the bounds of intensive malaria (check maps above). Studies show that malaria endemic countries in Africa have growth rates of up to 1.3% less than other countries that are not malaria endemic. For many countries in Africa this means negative growth rates.

Everyone knows about AIDS, but we have really overlooked malaria in the process.

But here’s the good news: this is easy to do. It doesn’t require huge investments in complex antiretrovirals, controversies over sexual abstinence, negotiations with drug companies, etc. It’s just sitting there.

The technology is relatively simple: insecticide-treated mosquito bed nets, better insulated door and windows, and anti-malarial drugs (which are quite inexpensive). As Jeffrey Sachs and his colleagues at the Columbia University Earth Institute demonstrate in a (relatively) recent paper, this would cost about $3 billion a year–0.3% of the projected stimulus package.

All of the bednets, insecticides, drugs and home fixtures could be manufactured in the United States, and could be done pretty quickly, making it a perfect candidate for the stimulus.

Note how this hits both domestic and foreign policy: it might be a nice opening move for an Obama Administration. Perhaps start the program in Kenya?

And of course if malaria eradication is successful, then Africa will achieve more sustainable economic growth, fulfilling the promise of the stimulus anyway.

Not all of the $3 billion would be in US products, but perhaps hiring a lot of idealistic and talented young Americans to train a new generation of African community health workers and administer diagnostic tests would also be an effective sort of jobs program. Very New Frontier, Peace Corps-like. I can imagine a potential incoming US Senator who should be interested in sponsoring such an initiative.

The Upcoming Stimulus Package: A Warning From Harry Hopkins

Virtually everyone says that the Obama Administration needs to create a huge stimulus package. Most of them think that it needs to be focused on public works. All very well and good, in my view.

But let’s not underestimate the political backlash that will inevitably follow. The source here comes from the man who should know: Harry Hopkins, who ran the Works Progress Administration in the 1930’s. The WPA is the subject of a readable new book by Nick Taylor, who relates the following conversation:

Hopkins was on a train trip with Hallie Flanagan, one of the pioneers of American experimental theater, who eventually ran the WPA’s Federal Theater Project. Hopkins’ warnings are directed toward the theater, but they apply toward any works project:

Can you spend money? It’s not easy. You can’t care very much about what people are going to say, because when you’re handling other people’s money, whatever you do is always wrong. If you try to hold down wages, you’ll be accused of union-busting and grinding down the poor; if you try to pay a decent wage, you’ll be competing with private industry and pampering a lot of no-accounts; if you scrimp on production costs, they’ll say your shows are lousy; and if you spend enough to get a good show on, they’ll say you’re wasting the taxpayers’ money. Don’t forget that whatever happens, you’ll be wrong.

Whoever runs any public works program from the federal level had better be an excellent administrator, and have political nerves of steel. Even if any stimulus is run through state and local governments–especially if it is run through state and local governments–it will be a favorite topic every night on Fox News.

Why does everything take so long?

Steve, Mark, Jonathan, and I have now weighed in on the importance of (i) deficit spending on an economic stimulus (ii) focused on investment rather than consumption (iii) that can get up and running quickly. Mark points at all the great research that didn’t make it into the outrageously stingy budgets of the last decade, but we still need to get off the dime in ambitious, big, expensive infrastructure projects of all kinds.

The “fast” criterion applied to construction raises a question that has puzzled me for a long time: why does it take so long to do anything physical, when it didn’t used to? Without computers, with truly primitive technology (rivets! and A7 steel) applied to really daunting engineering-frontier challenges (tunneling under two rivers), the entire Pennsylvania Railroad complex from New Jersey to Long Island, including Pennsylvania Station, RIP, was built in seven years, with the station opening in 1910. The railroad then built the Hell Gate system, connecting to the Bronx and New England, in four years. The IRT Subway, a cut-and-cover operation threaded through city streets and building foundations from City Hall to 145th St., opened four years after the contract was signed. And the Empire State Building (to pick just one other example from New York) took eighteen months from a shovel in the ground to a key in the door (still no computers, and still hammering hot rivets). New York has never been an easy regulatory environment.

Doing stuff fast is not an East Coast specialty: the SF Bay Bridge, two long bridges and a tunnel through an island, took just over three years; the Golden Gate, four. The Richmond yard turned out a Liberty Ship in about seven weeks, with three coming down the ways every day in 1943.

Whatever we had back in the day, we’ve lost it. Replacing only the eastern section of the Bay Bridge began in 2002 and we contemplate completion in 2013! And the Boston Big Dig, admittedly more complex than any of these except perhaps the IRT, took 13 years. We have a problem here: we’re apparently getting worse and worse at doing big projects, and delay is a big problem. A tract housing development can be providing shelter as soon as the first few units are built, but a bridge or a rail line just spins the meter until it’s finished. I don’t believe OSHA and the admirable drop in the death and injury rate for workers can be blamed; it just doesn’t take that long to put orange caps on rebar ends and tie off ironworkers to safety lines; same with environmental controls: pulling a cover over a dump truck takes minutes, not days.

Regulatory requirements for public hearings, and lobbying battles, delay project starts. This is costly, and should be streamlined. But it doesn’t trap millions and millions of dollars’ worth of physical stuff in an unproductive state for years. I’d like one of the first research investments of the Kleiman part of the stimulus package to be a full-court press on accelerating construction back to speeds we last saw in the middle of the last century.