A friend just returned from a family reunion in Ireland. A lot of his relatives are doctors. The Irish ones make less money, but they love their jobs, not least because they all have portable digital devices with all their patients' information (including, for example, x-rays) available at the touch of a button. My friend's American doctor relatives make more money, but none of them seem to have access to anything like the Irish doctors' portable electronic medical records: all of them are still doing some, if not all, of their record-keeping on paper.

This is silly, and the government is working to change it. The stimulus plan includes billions of dollars to support computerization of medical records. But in a great new cover story for the Washington Monthly, Philip Longman explains that the Obama administration may be doing it all wrong. Longman compares two hospitals that adopted electronic medical records around the same time: Midland Memorial in South Texas, and the Children's Hospital of Pittsburgh. Things went great in Texas, but terribly in Pennsylvania. "The devil, as usual, is in the details," writes Longman:

While many factors were no doubt at work, among the most crucial was a difference in the software installed by the two institutions. The system that Midland adopted is based on software originally written by doctors for doctors at the Veterans Health Administration, and it is what’s called "open source," meaning the code can be read and modified by anyone and is freely available in the public domain rather than copyrighted by a corporation. For nearly thirty years, the VA software’s code has been continuously improved by a large and ever-growing community of collaborating, computer-minded health care professionals, at first within the VA and later at medical institutions around the world. Because the program is open source, many minds over the years have had the chance to spot bugs and make improvements. By the time Midland installed it, the core software had been road-tested at hundred of different hospitals, clinics, and nursing homes by hundreds of thousands of health care professionals.

The software Children’s Hospital installed, by contrast, was the product of a private company called Cerner Corporation. It was designed by software engineers using locked, proprietary code that medical professionals were barred from seeing, let alone modifying. Unless they could persuade the vendor to do the work, they could no more adjust it than a Microsoft Office user can fine-tune Microsoft Word. While a few large institutions have managed to make meaningful use of proprietary programs, these systems have just as often led to gigantic cost overruns and sometimes life-threatening failures. Among the most notorious examples is Cedars-Sinai Medical Center, in Los Angeles, which in 2003 tore out a "state-of-the-art" $34 million proprietary system after doctors rebelled and refused to use it. And because proprietary systems aren’t necessarily able to work with similar systems designed by other companies, the software has also slowed what should be one of the great benefits of digitized medicine: the development of a truly integrated digital infrastructure allowing doctors to coordinate patient care across institutions and supply researchers with vast pools of data, which they could use to study outcomes and develop better protocols.

Read the whole piece.

A lot, of course. The New York Times reports that Goldman Sachs, "which only recently paid back its government bailout money, will report blowout profits from trading on Tuesday"—$2 billion in four months. The company is set to pay out $18 billion in compensation this year, which works out to over $600,000 per employee. In addition to the TARP money it received, Goldman was a major beneficiary of the federal government's bailout of AIG. But, you know, everyone does this sort of thing, so it's all good. Move along now—nothing to see here.

Behind the Curtain

Dan Drezner spent the past week guest lecturing at the Barcelona Institute for International Studies and reports back:

One mildly surprising finding from surveying my students was the extent to which many of them believed that the United States government was consciously manipulating every single event in world politics.  Ironically, at the moment when many Americans are questioning the future of U.S. hegemony, many non-Americans continue to believe that the U.S. government is diabolically manipulating events behind the scenes (For example, the Ghanaians in the crowd wanted to know why Obama visited their country last week.  The standard "promotion of good democratic governance" answer did not satisfy them, They were convinced that there had to be some deeper, potentially sinister motive to the whole enterprise).

Actually, the United States probably is trying to manipulate every single event in world politics. Dan's students were right about that.  The part they're missing is that they don't understand just how bad we are at it.  Answer: really bad.

Somehow, the battle over whether to require chain restaurants to prominently disclose nutritional information has become a hot button issue. And it could flare up as lawmakers consider enacting a federal calorie labeling policy. New York City reinstituted the practice last year, and California is on track to follow its example. But calorie labeling has so far stalled outside of these progressive havens.

Why all the controversy? As Ezra Klein writes, calorie labeling is such a good idea that it will "one day come to seem like the most natural thing in the world."

It turns out that the only drawback to requiring restaurants to disclose calorie information is that it could make people healthier... which could be bad for unhealthy restaurants and has therefore drawn the ire of the restaurant industry. In a brief following the defeat of a labeling measure in Maryland, the Restaurant Association of Maryland wrote that they do not oppose labeling but that they "simply want flexibility in how the information is displayed and nationwide uniformity through a federal approach." Will they show calorie information under the counter, or in the trash can, perhaps?

By giving consumers the means to make more informed, healthy decisions about their meals, calorie labeling fits perfectly into our capitalist ideals. The consumer can choose a 400-calorie salad from Cosi, for example, or a 1,000-calorie burger and fries combo from McDonald's. I, for one, know the euphoria that follows the knowledge that I just saved myself from 400 calories by ordering "fresco" at Taco Bell instead of my default 970-calorie choice Grilled Stuft Burrito and Double Decker Taco.

Why not let people enjoy the simple pleasures of eating healthy or unhealthy when they choose?

Is Treasury not getting the message? When it comes to administering TARP, the agency has been warned again and again about its lack of transparency by the three government watchdogs monitoring the bailout. Back in January, the Government Accountability Office concluded that goings on at the agency were so opaque it was difficult to tell whether Treasury even had a "strategic vision" for TARP at all. The agency has even tried to stonewall Neil Barofsky, the Special Inspector General for TARP (or, SIGTARP), refusing to hand over certain documents he requested. Meanwhile, Elizabeth Warren, the Harvard law professor chairing the Congressional Oversight Panel, has said that "without more transparency and accountability...it is not possible to exercise meaningful oversight over Treasury's actions." It must have been all the more frustrating for her when COP recently requested specific information about the stock warrants Treasury received from bailout recipients only to be told that none would be forthcoming.

At issue is whether Treasury is maximizing taxpayers' return on investment, or giving bailed out banks sweetheart deals by allowing them to repurchase their warrants at bargain rates. So far it looks like the latter. The COP's latest report [PDF], released on Friday, found "eleven small banks have repurchased their warrants from Treasury for a total amount that the Panel estimates to be only 66 percent of its best estimate of their value," shorting taxpayers about $10 million overall. While the agency has only sold warrants from smaller banks so far, if it were to unload its holdings under the same terms, taxpayers could lose out on as much as $2.7 billion. Given this, it would seem particularly important to find out how exactly Treasury is valuing these warrants. But this is specifically the information the agency is refusing to part with.

Here's news on the environment and health from our other blogs.

Medicaid Aid?: Should the feds use stimulus dollars for Medicaid?

Urgent Care: Kevin Drum muses on how urgent the healthcare crisis really is.

Drunk Driving: California Supreme Court reconsiders breathalyzer test results.

Sins of Omission: NPR gets chided for not calling torture... torture.

"Trillions in Spending, Billions for Babysitters? Nancy's 'Nanny-State' Enshrined in Legislation"—thus begins a policy document quietly released by the House Republican Conference (HRC) as the House Democrats introduced their big health reform package a couple of weeks ago.

The provision of the House megabill singled out for ridicule used to be a separate bill, HR2667, with one lonely GOP backer, Rep. Todd Russell Platts of Pennsylvania. As the HRC notes in its one-page brief, this provision would give states $1.75 billion in dedicated federal funds over five years to "improve the well-being, health, and development of children" via home visitation programs. It's intended to help teach low-income parents how kids develop, their age-appropriate behaviors and health issues, and "activities designed to help parents become full partners in the education of their children."

In short: babysitting.

Palin vs. Palin

The New York Times takes a look at Sarah Palin's post-campaign life up in Alaska:

Almost as soon as she returned home, the once-popular governor was isolated from an increasingly critical Legislature. Lawmakers who had supported her signature effort to develop a natural gas pipeline turned into uncooperative critics.

.... Her growing list of detractors quickly signaled that they were not impressed with her celebrity status. “We had business to do,” said State Representative Nancy Dahlstrom, a Republican who had worked on Ms. Palin’s 2006 race for governor. “It’s not all about adoration.”

....Democrats who had been crucial to her governing coalition now saw her as a foe. Republican leaders who had previously lost fights with her smelled weakness. An abortion bill she supported requiring parental consent stalled, the Legislature rejected her choice for attorney general and lawmakers became skeptical of the natural gas pipeline effort.

There was a lot more than just this, of course.  Among other things, there were money issues, personal issues, organizational issues, and an almost pathological inability to avoid a feud no matter how small or trivial.  But the fact that she found it almost impossible to govern Alaska after she returned obviously played a big role in Palin's decision to quit too.

Which got me to thinking: when was the last time someone ran for national office, lost, and then had to go back to being governor?  Answer: in the past 50 years it's happened only once, to Michael Dukakis after he lost in 1988.  And as you may recall, things didn't go swimmingly for Dukakis either when he returned to the statehouse — despite the fact that he was an experienced governor, didn't have any money problems, didn't participate in endless personal feuding, didn't try to position himself for another run four years later, didn't have tabloid magazines staked out in front of his house 24/7, was famously well organized, and had no problem discussing issues intelligently when called upon to do so.

In other words, maybe returning to run a state after participating in a brutal presidential campaign is just a tough assignment for anyone in today's media-saturated environment.  But Sarah Palin never figured that out, and if the Times is to be believed she refused to listen to anyone who tried to tell her.  As always, Sarah Palin's worst enemy was — Sarah Palin.

UPDATE: More here from the LA Times: "What is remarkable is the contempt Palin has engendered within her own party and the fact that so many of her GOP detractors are willing, even eager, to express it publicly."

Slaves to Farming

Dave Schuler laments:

As best as I can tell I’m one of the very few in the American political blogosphere who comments on trade negotiations — you can check back through my archives for my many posts posts on the subject. It doesn’t seem to be a subject that captures the imagination, possibly because there’s not a great deal of partisan hay to be made from the subject. I’d still like to know the answer to a question I posed nearly a year ago to Candidate Obama: how would he revive the Doha trade talks?

I sort of feel his pain.  But I'm not sure that lack of partisan venom is the reason for this.  More likely it's because everyone has just given up.  To me, writing about the Doha round is sort of like griping about how big states should have better representation in the Senate or musing about how we ought to eliminate the Defense Department.  I mean, if that's what floats your boat, fine.  The blogosphere is deep.  But we all know this stuff is never going to happen, so it's sort of a waste of time, isn't it?

Trade talks aren't quite that bad.  But they're close.  The Doha round in particular lives or dies based on the willingness of rich nations to substantially reduce tariffs and subsidies on agricultural products, and seriously, what are the odds of that?  We can't even have a serious discussion about reducing subsidies on corn ethanol, possibly the stupidest use of taxpayer dollars in the past century, let alone reducing farm support payments to ConAgra and Archer Daniels Midland.  Meanwhile, the European attitude toward farming makes ours look positively levelheaded and beneficient.  Paris would probably go up in flames if EU farm payments were ever rationalized.

So: what are the odds of making progress on agricultural issues?  Especially these days, you'd need scientific notation to express it properly.  Might as well wish for a pony instead.

Wagging the Dog

Here's an interesting little tidbit from yesterday's inspector general report on the various domestic spying programs known collectively during the Bush/Cheney era as the President's Surveillance Program.  The way it worked was this: the CIA at first, and later the Office of the Director of National Intelligence, produced a threat assessment every 45 days that was known internally as the "scary memo."  That memo was the basis for periodic renewal of the PSP.  If the memo wasn't scary enough, then no PSP:

CIA Office of General Counsel (OGC) attorneys reviewed the draft threat assessment memoranda to determine whether they contained sufficient threat information and a compelling case for reauthorization of the PSP.  If either was lacking, an OGC attorney would request that the analysts provide additional threat information or make revisions to the draft memoranda.

....During interviews, ODNI personnel said they were aware the threat assessments were relied upon by DOJ and White House personnel as the basis for continuing the PSP, and understood that if a threat assessment identified a threat against the United States the PSP was likely to be renewed.

Italics mine.  Now, the report dutifully goes on to say that the ODNI inspector general found the threat assessment process "straightforward, reasonable, and consistent," and that counterterrorism analysts believed the al-Qaeda threat to the United States was "overwhelming."

And yet — if that's the case, why would the scary memo ever lack "sufficient threat information" and need to be beefed up at the request of a CIA attorney?  And why would the IG's report go out of its way to mention, without comment, that the drafters of the memo were well aware that it needed to be sufficiently scary to justify the PSP?

Beats me.  I just work here.  But without saying so directly, the IGs who wrote the report sure seem to be going out of their way to suggest that sometimes the surveillance program was driving the threat assessment rather than the other way around.  Does that ring any bells?