Jon Stewart and the VA

Yesterday, Jon, in his program The Daily Show, had as a guest the former Chief Technology officer of the United States.  Those who watch The Daily Show will know that Jon has been deeply concerned about the handling of veterans' medical issues by the VA.

I share that concern and I heard Mr. Chopra put forward some useful ideas.  It seems reasonable that having the various uniformed branches generate patient medical information in some standard format that the VA's systems could then read would go a long way toward streamlining the process of moving responsibility for the care of injured vets from military to civilian responsibility.

I think the problem goes even deeper, though.  The real problems lie in the definitions of things.  For example, everyone believes we (the US) share a common language with Great Britain.  In fact we do communicate pretty well and there are very few words that don't cross the boundary.  Sometimes though a word seems to be understood and it isn't until later that we realize there has been a breakdown.

"Let's have a look under the bonnet" (or in "the boot") for example, often cause confusion.  The need to climb a flight of stairs to get to a "flat" on the first floor might or might not be important.  These examples illustrate the flighty nature of words.  Sometimes they mean one thing and then they mean something else.

In health care, even within the civilian area in the US, the goal is always precision.  When one doctor reads a clinical note about a patient written by another physician, any confusion at all causes delay which can be life-threatening.  At a minimum, confusion causes additional expense when diagnostic work needs to be re-done.

You'll have to trust me when I say that I could start an argument in any group practice by asking for a definition of "patient."  When a physician is presented with a gaping wound or a missing limb there is no doubt who the patient is.  Farther downstream in the process, though, once insurers, administrators, lawyers, legislators, and "family" have become involved, there can be a lot of doubt as to who the patient is.

The VA is simply the one left standing when the music stops.  They haven't created the problem and they will not be able to solve the problem.  I doubt there is anyone in Congress willing or able to envision and create a solution.  After all, there aren't enough veterans to dictate the outcome of that many elections--are there?

Hidden Glory

You may already know that the glorious colors we see in the fall are really there all the time.  If you don't know that--it's true and you can look it up.  So why do we see them for such a brief time in October?

Well, here's the deal.  The trees and other plants are busy staying alive from the moment the leaves first emerge in the spring until the shortened days after the autumnal equinox (fall) warn them at the cell level to start preparing for winter.  The flow of sap slows down and the green cells (chlorophyll) can no longer reproduce.  The green retreats closer and closer to the veins and finally disappears completely, leaving the other colors behind.

In short, staying alive makes all leaves look alike (green) while dying allows the underlying beauty to have the spotlight.  The metaphor is obvious.

People struggling through the day-to-day of staying alive often blend together in ways that mask the things that make them unique.  It's only when we're dying (or think we are) that our true colors are revealed.

No one knows the true beauty of another human being until that moment when it is revealed in struggle.  Those who are blessed never forget what they have seen and may begin to believe that the beauty, though unseen, is there now.  The truly blessed will begin to let that belief direct their actions.

Governor, You're Misguided

Before I begin, I do understand the complexity of balancing government services with minimizing the tax burden on citizens.  This balancing act is performed at every level of government including school districts.

I have lived and paid taxes in Iowa, Minnesota and Ohio both as an individual and as a business owner.  These things I know:

1. Ohio has far and away the most byzantine und unnecessarily complicated tax reporting structure I have ever encountered.
2. No business owner or entrepreneur makes decisions on where to locate based on tax rates alone.
3. As a partner in an Ohio business, I was required to make monthly and/or quarterly reports (and payments) to no fewer than five separate taxing bodies within the state of Ohio.
4. Each of these taxing bodies was interested in the same information with only a few minor differences.

Ohio's government is currently directed by self-described fiscal conservatives who advocate for smaller and more efficient government AND reduced tax rates.  The situation described above (1-4) cries out for simplification and streamlining.  One would think that this would be a natural focus for these [fiscal] conservatives.  Instead, we get promises of reduced rates with no reduction in complexity.  There seems to be an assumption that everyone has an accountant or a lawyer (or both) retained to handle the tax relationships with the State of Ohio.  If we really want to encourage entrepreneurism, we need to re-examine the entire Ohio tax situation.

One suggestion, Governor, is to give new business startups a three-year running start with no business taxes of any kind during that time.  From my own experience, starting a new business usually means doing everything yourself.  Tax reporting in Ohio diverts an amazing amount of attention and effort away from where it really needs to be.

Maybe in three years I'll be able to afford to hire an accountant and/or lawyer but until then I have to do it myself.  A side effect of DIY tax accounting is mistakes and the fallout from those mistakes.  It's really no wonder that so many new business starts last less than three years.  How much I pay is important but manageable.  How I pay is even more important and is unmanageable.  Most new business starts do not go to investment bankers, they are forced to use sweat equity wherein the owner's time is the most important component and the only resource with a hard limit.

Governor, saving those with incomes > $350,000 an additional $10,000 MIGHT help you get reelected but it isn't going to win you very many friends.

Flag Frustration

We just returned from a walk here in central Ohio.  During the course of this 20 minute walk we passed several businesses as well as a Post Office.  What I noticed this morning was the flag poles, each of which displayed the US flag and some of which displayed the Ohio state pennant as well as (in one case) an ISO flag.

Some but not all displayed the US flag at half-staff.

I spent several years as a Cub Scout/Boy Scout/Explorer and many more as an adult leader.  I spent 5+ years on active duty with the Air Force at bases and Army posts in Texas, California, Alaska and Berlin (which was not part of Germany at that time).  I guess I have soaked up something about the proper display of the flag.

1. ALL US flags are flown at half-staff or NONE are.  This is not individual choice.
2. No one is forced to display the flag so if we choose to do so, we owe it to the community to do it properly.
3. Half-staff is accomplished by raising the flag to the top of the mast or staff and then lowering it to a point (at least) one-third of the way down.  This half-staff position is designed to keep large flags from touching the ground or interfering with pedestrian or other traffic.  This may be especially important when multiple flags are flown from the same halyard (rope).
4. The flag should be in good condition and not visibly dirty or frayed.
5. Unless the flag is lit, it should be retired at dusk and during inclement weather. 

These come from the manual from which NCOs are tested to qualify for promotion.

If you search the internet for flag etiquette you will find many interpretations, some of which refer to laws governing flags and their display.  US law is summarized at http://www.senate.gov/reference/resources/pdf/RL30243.pdf

The President or the Governor of a state or possession may order flags in their jurisdiction to be flown at half staff.  There is no authority for anyone else to do so.

Why display a flag?  Some sites are prescribed in the law.  All others are optional.  Typically the flag is displayed in the interest of patriotism.  While feelings of patriotism are desirable, display of the flag for this purpose is optional.  A patriot will become informed about the laws and traditions in order to display the flag intentionally to reflect on himself and his country. 

I'm going to try to put this aside now so that I can enjoy my walks again.

PRISM and Me

Nothing that calls itself "news" is complete today without offering something about the NSA's project (called PRISM) to gather information about telephone and internet traffic.  My ears perked up when I heard the term "metadata".  Call me a geek or a wonk, but data has been where I lived for the past thirty years. 

Getting anyone at all to pay attention to something called metadata has been harder than making the average person care about mathematics or history.  Now that it's out there in the public vocabulary, its use brings up several other issues.

1. The use of the term seems calculated to disarm suspicion.  It's just metadata about your communications and not the communications themselves so don't get your underwear in a knot.
2. The term is used in a way that is inappropriate to the issue.  It wouldn't matter to the issue of government intrusion if it was the actual communications that were being monitored.
3. I heard a man on a call-in show the other day talking about "my information" as though he were the owner of the information merely because it concerned something that he did.
4. There has been much discussion of exchanging privacy for security.  That discussion is moot when the privacy being discussed extends only to data.  If there is anything at all to be learned from cyber-bullying or phishing scams or on-line impersonations it is that the information itself has no value.  It is only the use to which the information is applied that has any ethical or moral value.  I realize that this is the same argument advanced by gun control opponents but on this, at least, they have a valid point.  THERE IS NO PRIVACY.  THERE IS NO SECURITY.  There is only more (or less) private and more (or less) secure.
5. Finally (for this post) the term metadata is defined in these reports as data about data.  This is semantic sleight of hand.  What is data and what is data about that data shifts as we go from person to person or perspective to perspective.  ATT and Verizon do not record calls (we hope) so the information being gathered by the NSA is data and NOT metadata.  The information is what the communications companies use for billing purposes.  Yes, from the perspective of the caller or the callee, this could be thought of as metadata if they thought of it at all prior to PRISM but here is a case in which a new piece of knowledge (or data) causes the world to recognize something that never existed before--namely metadata about their communications.

Is the government (in the person of an agency, NSA, tasked with National Security through application of electronic rather than human resources) acting legally?  Given that the government defines "legal", the answer has to be "Hah!"  This is what the NSA does on a worldwide basis though not usually by coercing companies into handing over information.  Would the answer be any different if the NSA hacked the corporate servers that store all of this communication-related data?

Bottom line: if situations like this one are the only time we pay attention, we deserve whatever happens.

Jon Stewart Don't Know Squat About Data

This past Wednesday (Mar 27, 2013), the Daily Show included a segment on the backlogs within the VA and found the cause to be

• The reliance on paper to transfer medical records between the DoD and the VA

So far, so good. Good investigative reporting. If they had only left it at that and allowed viewers to form their own conclusions...

Instead, John Stewart made a joke about validating his preconceived ideas concerning Republican responsibility. He played a clip of a Republican member of the Defense Appropriations committe comparing AHLTA (the DoD healthcare information system) and VistA (the VA's Healthcare Information umbrella) to Play Station and X-Box which, though both can use the same TV, cannot talk to one another. AND THEN Mr.Stewart suggested that the parent of the household, if he/she wanted to minimize contention and confusion, could impose a single solution on the household. A photo of President Obama was displayed during this, clearly indicating that all the blame could be laid at the President's feet.

Nothing could be further from the truth. The VA has been assembling the components of VistA since 1987 and it was fully formed by the late 1990s. AHLTA was introduced amidst much fanfare at the beginning of 2004. The birthing process for AHLTA overlapped the adolescence and maturation of VistA, indicating a conscious decision (pre-2004) by the DoD to ignore the VA's efforts.

This entire mess is too complex in its origins and effects to discuss in a single blog entry so I'll content myself with one last piece of exculpatory evidence on behalf of anyone who has assumed elected office since 2004. The only way to move information from AHLTA to VistA is

1. Generate paper from AHLTA
2. Send the paper to the VA
3. Enter the information from the paper into VistA

This is also the reason why the DoD can't simply replace AHLTA with VistA.

There is a lot more to be said on this subject but, among other things, it seems clear that this is but one (albeit very painful) example of the inability of our health care "system" to adopt anything approaching a standardized view of the enterprise. Interoperability is something to be wished for but which cannot exist in an environment in which healthcare systems vendors are the X-Box, the Play Station, and Wii.

Violence and Firearms

A statistic led me to this point.  In reporting on the NRA's response to the Newtown tragedy, the networks reported that the organization has 4 million members.  I was struck by the small number and how disproportionate was their influence.

In a nation of 300 million people, how does 1.3% of that population get to control the debate on the regulation of firearms manufacture, sales and ownership?

Some background on my perspective: I have owned several firearms--as many as three shotguns, two rifles, two handguns and an air rifle at one time.  I enjoy hunting, target shooting and taking care of the weapons.  I do not own or possess any firearms currently.  In the interests of full disclosure, I should also say that I have been a member of the NRA.

Now that those cards are on the table, my opinion of the NRA is that it is an extremist organization.  When I was a member, I was sent messages and asked to pass them along to my elected representatives and/or network media figures.  The language in these messages was, to my mind, extreme and I could not, in good conscience, do as requested by Wayne Lapierre or Charlton Heston.

So how does the NRA wield so much influence?  It's mainly because their voice is the well-orchestrated one.  A voice for something always drowns out the voice against.  They have consistently made the issue about the Constitution and for a right cited in the Second Amendment.  The opposition, such as the Brady Campaign to Prevent Gun Violence, is portrayed as being against the "right" cited in the Second Amendment.

This much is obvious, right?  It's also obvious that the voice that is heard is easily interpreted as the majority.  The NRA is very good at whipping up a frenzy of fearful indignation amongst the membership.  They can generate 4 million (I don't imagine there were too many others like me) emails, letters and phone calls, frequently to multiple targets.  The Brady Campaign can't do this nearly as well.

As we saw in Mr. Lapierre's most recent statements, it is easy to sow seeds of confusion and generate several tangential debates while all the while adamantly holding the flag of the Second Amendment high and calling on loyal Americans to rally to its defense.

In fact, there is no justification for high-capacity magazines and high rate-of-fire except as a thrill for certain kinds of enthusiasts.  (There must be another term for an enthusiastic extremist--or maybe enthusiastic is redundant.)  You can get quite a thrill from cocaine or meth, too, but those thrills are illegal.  I have been in the woods during deer season and heard a single weapon discharge 10,15,or more rounds in the space of a few seconds.  It made me profoundly uneasy as I sat there with my single-shot rifle.  Thrills for a few are not sufficient justification for the level of danger presented.

The Second Amendment could be satisfied with a muzzle loading black powder weapon.  Let's shrug off the "right to keep and bear arms" as the central issue and stay focused on issues more central to the public welfare.