Sorry, your test results are secret

In Tuesday's NYT there was an investigative piece about the "Health Insurance Portability and Accountability Act" [Hipaa].

In a supposed desire to uphold the 1996 law protecting the confidentiality of patient medical records, health care workers -- principally nurses and office workers -- refuse to disclose medical information to family members, public safety officials (investigating police officers or social service workers) and even in same cases other medical professionals not directly assigned to the patient at the time of 'official' treatment.

As well meaning as the legislation is -- there's a clear need to ensure that the medical records of a person remain private -- it's fraught with unintended consequences largely the result of poorly trained providers. Workers in the medical facilities refusing to disclose necessary medical information to next of kin or other appropriate bodies and an enforcement system (Health and Human Services) oblivious to the need for ensuring intelligent ("common sense") design and implementation.

The situation of its implementation has gotten so bad that someone related that "A lab technician once refused to give me a copy of MY OWN lab results at a lab. where I had a lipid profile, on the grounds that it was prohibited by Hipaa."

In an interview with Susan McAndrew, deputy director for health information privacy in the Office of Civil Rights at the Department of Health and Human Services one quote jumped out at me:

Q. I also could not figure out, either from the website, actually reading the law or interviewing both providers and privacy experts, whether your department took or investigated complaints about unnecessary or inappropriate withholding of information.
A. Failure to exercise discretion is not a violation. If we receive a complaint or inquiry about non-disclosure to family or friends, or non-disclosure to another health care provider, we don’t investigate those cases because they’re not subject to enforcement action. We deal with those situations on an education level. [emphasis added]

It's that kind of attitude that generated the stack of letters the NYT published in response to their original article.

A number of letters came from children or other family members who had sought information about about their family member, only to be denied because of hippa laws, including this situation:

My father in Florida was in a hospice and I was in California. I called to check on his condition and was told they could not inform me because of hipaa laws. I yelled and screamed at them. I became very distraught. Later I found out that he was already dead at the time of that conversation and they wouldn't even tell me that.

Another letter related how even with the "patient" beside him, he was asked to leave the room when they discussed her medical condition:

In 2004 when my wife and I had an insurance coverage issue, we met with the Human Resources manager at my wife's employer. The HR director said that she couldn't discuss that matter with me because it would be a violation of Hipaa. Even though I was sitting right beside my wife!

Then there are these two stories:

1. I have a hard time remembering the names of my prescriptions, but Kaiser Permanente pharmacists refused to let me look at my very own screen on their computers, to ask for what has been prescribed to me. (Now I keep a list in my purse for this purpose.) 2. When my aunt's caregiver (Auntie is an alcoholic with dementia) went to the hospital and I was trying to decide what to do about her care I wasn't able to find out WHICH hospital or her prognosis until after her death, some five days later. I had no clue as to seriousness of the problem, and I was trying to cope from 3000 miles away, since I make medical decisions for my aunt.

One writer suggested that patient care is compromised as other care givers are denied previous medical information.

As a radiologist, I have found the legislation to be nothing but a headache that
detracts from my ability to provide the best possible care [for] my patients, ...
[particularly] as a patient moves from provider to provider.

It can be very difficult for a radiologist to get clinical data and follow-up information about a patient. Examples: 1) Patient is having a M.R.I. at our imaging center. I call for a report on a prior M.R.I., done at another institution. Staff will refuse to fax it over ... 2) Patient is having a MRI of the knee at our imaging center. The patient has had arthroscopic surgery on that knee. I call for an operative report. Staff will refuse to fax it over. 3) Patient has a shoulder M.R.I. at our center, and has some unusual findings. The patient has surgery on the shoulder, and I call over for the operative
report. By knowing what the intraoperative findings are, I improve as a radiologist, and the next time I see these findings, I will recognize them for what they are. This is one important way doctors improve over time - getting feedback on their performance. Even though I am a consultant to the referring physician, the office staff will refuse to fax me the operative report. [emphasis added]

The absurdity of how the law is being managed is illustrated best by how the article ended

A hospital spokeswoman, Elena Mesa, was asked if nurses were following Hipaa protocol when they denied adult children information about their parents. She could not answer the question, Ms. Mesa said, because Hipaa prevented her from such discussions with the press.

59 and counting - reflections on Israel

The Israel "Holy Week" -- Yom HaShoah [Holocaust Remembrance Day] through Yom HaZikaron [Memorial Day for those killed in service to the country or as a victim of terrorism] and lastly Yom Ha'atzmaout [Independence Day] -- is completed so it's time to reflect upon how each day illuminates the current Israeli reality.

Yom HaShoah was established to be observed exactly a week before Yom HaZikaron. I assume that was done to reinforce the idea that there's a direct connection between the horrors of the Shoah [Holocaust] and the Nazi death camps of WW2 and the creation/establishment of the State of Israel. Unfortunately, it's connection is more conceptual than actual.

• This year it was reported that more than one-third of Holocaust survivors are living under conditions of dire poverty.
• The Israeli government has been accused of being slow and negligent in ensuring that the pre-war assets (bank accounts and property) of those who perished during the Shoah are returned to their surviving family members.
• With the exception of "official" acts -- the establishment of Yad Vashem, the active work in bringing over survivors from the Displaced Persons' camps, negotiating reparations from Germany and the pursuit of Nazi war criminals -- there was little effort expended to help make the survivors' lives easier. Frequently, survivors were 'encouraged' to establish a new identity (e.g. changing their name) in Israel. Their struggle wasn't recognized by allowing them to 'work through their issues'. It may have gone so far as to use the example of the Shoah as a paradigmatic example of "Galut" Jewish life and how the Israeli (no longer powerless militarily or subject to foreign governmental and cultural influences on their daily lives) was the new Jew. Hebrew not Yiddish was the "Jewish" language.

Yom HaZikaron is observed the day before Yom Ha'atzmaout, to reinforce and concretize the sacrifices made to maintain the State of Israel. While it's certainly true that there's a direct connection between the two days, it's often difficult for those families who lost an immediate family member to make the necessary shift from active mourning their family member (father, child, sibling) to joyously celebrating Independence Day.

• In last week's The Jerusalem Post weekend magazine it was reported that non-married [married = common-law or 'sanctified'] partners of killed soldiers are not recognized for IDF services -- survivor benefits and more problematically psychological assistance -- to assist them cope with their loss. Only direct family members are entitled to services. While a non-profit organization has been established (with some assistance from the IDF), the struggle of significant others remains a serious and not fully recognized issue. Even those who later married continue to carry the scars of the death of their earlier lover for many years.

What does all this mean? To me, it seems that the country has its own set of rigid expectations and that anything or anyone who falls outside the drawn lines is left to fend for themselves.

It's 1, 2, 3 Strikes ... [2]

During the last month or so, there has hardly been a day without one strike or another.

• The post-elementary teachers are on strike for a better deal with the Finance Ministry, who after all, they are among the lowest paid teachers in the developed world and lowest paid workers (even assuming an advanced degree and 15 years experience) in the country -- less than 5,000 NIS a month [~USD 1,250] or USD 15,000/year.
• The Port of Ashdod was on strike.
• The Israel Electric Company against the proposed, and now legislated, privatization plan which would ruin their benefit of free (and unlimited) electricity.
• The university students are/were on strike to protest the government committee that is expected to call for a tuition increase (to cover the shortfall created by the diminishing government contribution to higher education).
• The National Insurance Institutions (social security) because they wanted better working conditions including money.
• On and on ...

Tomorrow is a threatened nation-wide strike called by the Histradrut [the National Federation of Workers] to protest the lack of payment (salaries), some up to 10 months, of various municipal employees throughout Israel. The government issued a number of promises to address the issue. However, some 1,000 people remain waiting for their paycheck for 10 months. Lots of excuses are offered by the government -- the ministries of finance, interior, PMO (responsible for the local religious councils) -- but, of course, little action. Ironically, this group -- many of whom worked in Arab (read non-Jewish) areas -- has continued to show up and did their work despite not being paid (kind of silly too). I really feel for their plight and it's a real embarrassment that the government and the country has allowed it to continue this long.

Unfortunately, like all the other strikes I'm not sure the actions are being targeted appropriately. I mean, if you're trying to influence an insensitive government, why inconvenience the general public? The public, also unfortunately, has little if any influence on government action. Among some of the reasons is that no Member of Knesset [MK] is directly responsible to any geographically identified population. They're completely reliant on some part of their party -- the central committee or in some cases the entire membership who voted for the party election list.

If the target is the government, why not withhold services that government and its ministers require? Collect the garbage, but instead of bringing it to the dump, place it on the lawn of the nearest Minister or the Prime Minister's residence or the Knesset grounds. Have each of the municipal employees call/fax the government inquiring when their back paychecks will be direct deposited. Encourage the government aides to refuse to do their work, thus making the Minister do all the work. Picket them at their homes. Generally, make their lives so disagreeable that they feel it necessary to resolve the workers' issues quickly and in good faith.

And, yes, I know it's all just a (pipe) dream.

It's 1,2, 3 strikes... [1]

For the last week or so Esterina Tartman, a MK from the Israel Beitanu party and a close confidant of its leader Avigdor Lieberman, has been the subject of a number of exposes.

1. When an Arab member of the Knesset [MK] from Labor was about to be appointed to the cabinet, she expressed her opinion that Arabs have no place in the government, since Israel is a Jewish state -- "I am in favor of a Jewish and democratic state," and suggesting that the appointment of Ghaleb Majadele was tantamount to "swinging a gigantic axe at the tree trunk called Zionism and the Jewish state." Her racist comment didn't garner her any positive feedback/support from the general public.
2. It was disclosed that several years ago, she applied for (and was granted) disabled status from the results of a traffic accident by the NII. She claimed that she was only able to work four hours per day. She also received a settlement from the insurance company.
3. This week it was disclosed that she lied about her academic credentials. She doesn't hold a BA (in economics from Bar Ilan U) or an MBA (from Hebrew U).

With a shuffle of the cabinet, Israel Beitanu received an additional cabinet post (Min of Tourism) and the chairship of the Knesset Finance Committee (whose current chair has refused to set down despite his party refusal to join the government coalition -- but that's another story). Tartman was designated as the party's choice for the Tourism post.

With the revelation of her falsified resume, her "star" had fallen. Late yesterday, after it had become clear that her candidacy had garnered opposition within the Knesset and she might not get elected, she announced that she was withdrawing her name from consideration. Another party member replaced her.

What was most interesting here is not that it was another sign of how corrupt the government or the political system is but, how Tartman and Lieberman expressed shock and outrage how "the media" treated them. Instead of expressing contrition at their misdeeds, they accused the media (and I assume also the public) for their "witch hunt". For Lieberman, her misrepresentations on her resume were no big deal and an innocent mistake.

Who's Lieberman fooling? It was calculated act. Her "problem" is that she and the party got caught. It would do the party, the government and the country good if its leaders were actually above ethical (never mind legal) reproach and when they 'fail', they acknowledge their error in judgement, preferably before it becomes media fodder. However, even after it's reported accepting responsibility for their behavior would also be appreciated.

Lastly, it's another reason for reforming the electoral system. See David Horwitz, Editor's Notes in last Friday's (23 Feb) Jerusalem Post.

A kiss is NOT just a kiss ...

This afternoon, the court announced its verdict for Haim Ramon, the ex-Justice Minister. He was found guilty of preforming an indecent act by (french) kissing a female soldier attached to the Prime Minister's Office. The entire country is in shock. The guilty verdict wasn't really expected. A matter-of-fact, the judgement (written decision) wrote that the accused's version wasn't at all acceptable or even logical. It was a stinging rebuke to Ramon and it may not allow him to launch a reasonable, or successful, appeal. Sentencing will occur at some later date. What seems clear is that this conviction, no matter what the actual sentence, signals the end of his political career (nevermind, any hope of returning to serving as Justice Minister or any other cabinet position).

After watching a number of news programs with their "talking heads", I'm left feeling confused about whether it was a good decision -- something to celebrate -- or, a real setback to the advance of women and the law.

On the one hand, the act was reprehensible and deserving of some kind of penalty/punishment. He certainly overstepped his authority and took advantage of a young woman (whether or not, as Ramon claimed she had consented to, or even encouraged, his advances).

On the other hand, I'm not sure of it was worth of being convicted of a criminal act. As Yael Dayan, a former Member of the Knesset and Chair of the Women's Status Committee where she was responsible for creating and advancing feminist legislation, said on one of the programs I watched, the act fell more into the area of harassment than criminal indecency. She also differentiated his situation from that of Moshe Katsav. In the former case [Ramon] his indictment didn't create an avalanche of additional complaints of harassment/indecency unlike what happened with Katsav. That suggests that it was an isolated (individual) act.

While I'm not sure Ramon's behavior with this woman was an isolated act, it also wasn't part of a serial behavior of sexually harassing women (which can't be said for Katsav).

What I do sense is, Ramon is being punished for the poor behavior of other, past, politicians -- including Yael Dayan's father Moshe -- who engaged in numerous affairs during their terms of office. It has become a case of bad timing. He was caught in a paradigm shift as the public mores have shifted towards greater sensitivities of women.

That in itself, is something to celebrate even at the cost of destroying the career of a beloved -- if the public expressions of support and shock by other public and political figures are to believed -- public official.

The government you deserve

Last Friday's [12 January] New York Times' Letters of the Editor was devoted solely to George Bush's national address as he called for an increase -- for an undefined temporary period --- of some 21,500 more American troops (soldiers). While, I certainly agree with many of the criticisms made of the President and his Administration policies, I find it strange the volume of of the outcry. Has his recent pronouncements represented a large change from those during his first term? Has he gone back on campaign promises/commitments made either during 2000 or 2004? Has the administration changed its approach to governing, and then reversed itself, that is disturbing the American people? What's changed, that now people are upset with the Bush government and its policies in general, and the war in Iraq in particular?

Comments from the letters like:

The president, in his speech to the nation on Wednesday, said, ''For the safety of our people, America must succeed in Iraq.''
If the safety of the American people had been considered in advance by a competent president, we would have never mounted the unnecessary invasion of Iraq. [J. Knowles, CA]

America is well aware that Mr. Bush's strategy for war in Iraq was fundamentally flawed from Day 1. This new plan is no exception.
The newly elected Congress and Senate must find a way to stop him. [M. Haskett, TX]

More than 20,000 additional troops are being put in harm's way on the say-so of one man. Isn't that more characteristic of a dictatorship than a democracy?
Why isn't Congress mounting a more vigorous effort to block money for this ruinous war?
Our senators and representatives cannot allow George W. Bush to try to salvage his failed presidency over the maimed and dead bodies of our men and women in uniform. [G.G. Weiss, NY]

One letter hit the nail on the head:

The fact that America re-elected this self-absorbed, limited politician puts the blame not just on him but also on the American people. There is no glory in ''staying the course'' so that President Bush can prove he was right.

Which leaves me with a few quotes to end:

Democracy is a device that ensures we shall be governed no better than we deserve."George Bernard Shaw (1856 - 1950)

"Every country has the government it deserves"-Joseph de Maistre (1753 - 1821) Written on August 15, 1811

In a Democracy, the people get the government they deserve - Alexis de Tocqueville

A lonely bush in Iraq

Last night's address by President GW Bush was another example of how the current White House is tone deaf to the voices of Americans. It was also an example of 'if force doesn't immediately solve the problem, apply more force.' Instead of presenting a new strategy for addressing the Iraqi quagmire and how America can help set Iraq (and America) on the right course, it was an exercise of flogging a dead horse. While his words sound nice, the implication of his speech is "same old, same old". Only this time he's added a few twists.

Dan Froomkin, writing in the Washington Post is quickly becoming one of my favorite columnists. In yesterday's article [Tuesday] he discussed what GWB could make of his address. In Wednesday's, which I assume was actually written prior to the address, he offered a critique of the expected points to be made.

From my perspective, Bush's address failed the "Froomkin test."

Both the results of the mid-term elections in November and the current opinion polls provide a clear message. The war in Iraq needs to be fought without outside (read American) military forces. The refusal of the administration to acknowledge the errors that got the US so deeply into the war and their refusal to acknowledge the generally accepted 'reality' of the situation in Iraq and, thus, creating a withdrawal plan for the US troops, coupled with their general (typical) arrogance to either engage Americans (especially those who don't agree with them) in a real discussion/debate about American priorities or listen to actual experts and the American people, has left the administration with an abysmal approval rating and a dearth of trust. The "bubble president" is finding himself behind his own brick wall (dare I see 'iron curtain'?). He seems to have created his own little world and reality, which psychologists refer to as "psychosis."

Instead of proposing to send more US troops to address the civil war/ insurgency in Iraq, he should have publicly acknowledged that it's the American presence that is the driving force behind the deterioration in Iraq. Redeployment of the active forces to outside of Iraq is in the best interests of the US:

1. It will take away the raison d'etre for many of the insurgent groups. Instead of uniting against their common enemy -- America -- they will be forced to address their differences and hopefully become convinced of working together to create a peaceful Iraq (maybe even a democratic one).
2. It will allow the US to free up its military forces to address other conflict areas or promoted "American interests". Say, confronting rouge nuclear countries like North Korea or Iran, promoting global security like places like Africa (Darfur and Somalia), confronting international terrorism (al Qaeda et al) and prepare for the new world order -- the growth of China and Asia as well as assisting in emergency situations (e.g. natural disasters like the tsunami of 2004).
3. It could help reduce the anti-Americanism and general anti-West feelings throughout the developing world.

"Staying the course", or whatever the current Bush phrase is, will only leave America and its articulated values weaker.

Hopefully, the Congress will exercise its constitutional powers of oversight and help keep America strong until the end of the Bush presidency.

Rotten to the core?

The level of corruption in Israel political life and the government itself has become epidemic.

• In today's news it was reported that the Finance Minister, Avraham Hirschson, is under police investigation for complicity in a case of embezzlement at a non-profit organization during his term as the Chair of the Board. (They are trying to determine if duly reported the crime to the proper authorities.)
• A few days ago, it was announced that the Tax Authority leadership plus the Bureau Chief of the Prime Minister's Office along with a few businesspeople (one of whom was the brother of the PMO chief) were under investigation for bribery.
• A week or so before that, it was announced that Inspector-General's point-person for examining government corruption, a former high ranking police officer, was done under investigation for corruption. It's alleged that he was in contact with the [Ariel] Sharon family offering to allow the accusation of corruption to die in exchange for being appointed the head of the Israeli Police.
• The criminal trail of former (Justice) Minister Haim Ramon for sexual harassment is winding up.
• The decision to indict President Moshe Katsav, who's been beleaguered by accusations of sexual harassment, corruption and abuse of power for the last six months or so, is expected shortly. If indicted, he promised to resign. However, recently there's been some backtracking (mostly via his lawyers and friends).
• The Chair of the Knesset Security & Foreign Affairs Committee, Tzachi Hanegbi, continues to be under investigation for his involvement in corruption (patronage appointments) and financial irregularities at a charity he headed. He has not resigned his position.
• There's the on-going investigations into Avigdor Lieberman (currently the Minister for Strategic Initiatives) which has been going on for the last eight years or so (which might have been closed) and the possibility of a new one. He's not a really popular character, except for those who vote for his party, so it's also possible some of the criminal accusations are politically motivated.
• Then, there's the ongoing investigations into the activities of the Prime Minister himself! Ehud Olmert (not a favourite of mine!) has been in and out of court over various accusations of corruption. Now there are two more police investigations about his behaviour as Minister of Industry & Small Business and as the Finance Minister. We'll see where they lead to.

Then there are the past accusations, which lead to convictions:

• During Ariel Sharon's last term as PM, there were a number of accusations. His son, Omri, was sentenced to a jail term. His other son, Gilad may also have been sentenced.
• Naomi Blumenthal was convicted of bribery/breach of trust for paying for Likud party activist to stay in a hotel, and then lying about it, to have them vote for her during a primary election. Upon indictment, Ariel Sharon fired her from the cabinet.
• Aryeh Deri was convicted a number of years ago for accepting kickbacks for arranging land deals, while he was the Minister of Interior and responsibility for the Israel Land Authority.

I'm sure I've missed (or mistaken) several other incidents of corruption. And above list only represents national public figures. The cities and regional councils have been excluded.

There seems to be a permanent cloud of suspicion of corruption hanging over the Israeli governments and public service. What's going on?

A large part of the problem is the lack of accountability to the public. Politicians are beholden to their political party and especially to the central committee who votes for them and assigns them their party ranking on the ballot. So, instead of having to compete for the trust of a specific geographic population, who could challenge them to perform more ethically and serve their needs, politicians do what they must to convince their party of of their worth to be placed high on the party list. (Only the Labour Party has an open primary among its members to determine the party list. The rest of parties determine their list by central committee).

Another factor is the historical dependence on the government to determine national priorities. It seems that the government, especially the Knesset, is the central national institution. There's a tiny voluntary sector and a vocal extremist polity to challenge the government to adjust its priorities to better reflect the larger concerns of the Israeli public.

The net result is a country ruled by elderly party leaders -- who've done their duty to the party and refuse to step aside for the younger leaders, unless forced -- who seem interested in advancing their personal agenda, even at the expense of the larger Israeli society.

Saddam hung to dry

The hanging of Saddam Hussein last Saturday morning may have been a momentous occasion, however, I'm still not sure it was a positive step for Iraq, the region as a whole, or the world. What was the rush to kill (execute) Saddam Hussein? His death spells the end to all of his court trails and the possibility of having all the actors -- including Saddam -- of the 30 year reign of terror held accountable for their actions and involvement (by having them blame Saddam for every thing). Several questions remain:

1. Iraq

• Has all the information about Saddam's personal role been made public?
• Does his death create obstacles/problems for effectively continuing with all public trails of other government/military figures?
• Is his death an opportunity for a cessation of sectarian violence or the catalyst for increasing it?
• Will this strengthen the Malaki government or further weaken it?
• How will Iraq deal with it? Is this the beginning of the end (or Iraq) or the start of building a stable Iraq?

2. US

• Is his death enough for GW Bush to declare victory and start an immediate pull back (at minimum) or full withdrawal of US forces from Iraq?
• Does this enhance (or detract) from GWB's standing in America and the rationale for invading Iraq?
• How will the military situation change because of this?
• Does this advance American interests and international standing or, is it another thing to add to the (growing) list of American foreign policy blunders?

3. The region

• How does this death effect the influence of other regional players, especially Syria and Iran? What about Saudi Arabia?
• Is this a blow or a boon to Islamic terrorist/jihadi groups, especially Al Qada?
• How does this affect the Lebanon and the Arab (Palestinian)-Israeli conflicts?
• Is this a setback or an advance for democratization?

4. The world

• Is this a blow or a boon for international terrorism and Islamic jihadism and sectarianism?
• Does this provide a window of opportunity to internationalize the conflict; i.e. greater involvement for the U.N. and other international organizations?

Personally, I'm not that sanguine that his death will create the necessary conditions for "solving", nevermind, stabilizing the situation to let the Iraqis run their country by themselves. The country is too weak to withstand all the foreign interests seeking to influence Iraqi policy and life. The US administration's poor post-war planning -- immediate and otherwise -- allowed chaos and other foreign influences to take hold that the civil war will be a fact of life for the near term (at least 2-3 years). Unless the US, and particularly GWB, announces a realistic and timely (close to immediate) timetable for the removal of their troops from Iraq, the situation will get worse before it gets better.