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Month: October 2017

Physician, Heal Thyself!

Physician, Heal Thyself!

No, this isn’t about drugs or addiction or ODing, or any of those things. It is about frustration, though. Frustration with the medical profession. Frustration in trying to create sense where sense seems not to exist. Frustration that can lead to scenes such as in the image. Fall down on the floor, tear out your hair, rend your garments sort of frustration.

To be perfectly clear, this posting is based on a personal incident – drama is more like it – playing out now with certain elements of the medical profession. To protect both the innocent and the guilty, I’m not going to name any names. Now. But if I continue to be stymied, that decision might change. Watch this space.

If you’ve read my piece on The Biggest Shell Game in the World, which you should before reading on here, you know how I feel about the so-called “healthcare system” we have in this country. You’ll also see I elaborated on some specific actions that might help ease the growth in the cost of healthcare. That posting focuses on the macro dynamic of the system. This posting focuses on the micro dynamic, the one on the doctor level.

It’s no longer a laughing matter – it never was a joke – to say that much of the medical profession is still anchored, not just in the last century, but maybe even the one before it.

When I lived in Montana some dozen years ago, my physician – an author of the reputed Helena Heart Study, so no slouch – presented himself as advanced because he took his notes on a laptop. Why that should have been considered advanced when small computers had been in fairly wide business use for a quarter century already is a good question to ask, if you’re inclined to ask questions. Now, all the doctors I go to use laptops for their notetaking and recordkeeping. Of course, it is, at last count, 2017.

The one thing my Montana doctor did that really stood out was to communicate by email. Quick, easy, asynchronous. Email. One would think this also would be pretty standard now. That’s what I thought. I mean, I run a global business and communicate with clients all over the world at close to 100% by email. So picture my surprise to be out of Montana and in a southeastern state that also shall remain nameless (besides, I often reverse the “d” and the “i” in the name, which is embarrassing) and to find that email does not play a role in typical doctor-patient communication.

Does one even have to wonder why calling a doctor’s office often leads to more frustration, lengthy stays on hold listening to dreadful “hold” music and self-serving promotions, being asked, finally when you get past the official hold, “Can you hold, please?” (Okay, at that I’m tempted to fire back, what are my options here?)

Again, how can almost any organization in 2017 function without email? It’s not only a fast and easy means of communication, but it also can be used as a system of sending health information to patients and even, if one is allowed a bit of crassness, as a marketing device. But, no, this seems to be beyond the understanding of most doctors.

Then there are those doctors’ portals. Potentially great idea, completely mutilated, misused, and just plain not used, in execution and practice. First, they’re all clunky in that clunky way that special-purpose software (like used in lawyer and, yes, doctor offices) always is. I don’t know, maybe it’s me, but I’ve had a litany of problems with the portals of several doctors and healthcare groups. Sometimes I’d have to enter a new password each time I signed in. Sometimes things I’d want to see, like reports, are there. Sometimes not. One portal doesn’t even tell me my next appointment, which would seem pretty basic. I’ve yet to be able to get a prescription refill put through based on a request posted on a portal site. And, perhaps the biggest issue I’ve encountered, often doctors’ front offices don’t mind the sites, so sending a message to the office through the portal is like throwing a quarter down a deep well. “Pathetic” is too kind a word.

Okay, despite all that, that’s not my biggest problem nor the most immediate. Oh, no. I have a far bigger gripe, which we’ll get to now. The one that concerns the Health Insurance Portabliity and Accountabillity Act – HIPAA – and how doctors not only seem not to know much about its requirements but, worse, seem to think it exists to protect them and not the patient. Which is wrong.

I had one doctor earnestly tell me that there is a $50,000 fine attached to a single HIPAA violation. Well, he was part right. Fines can range from $100 to $50,000, or $1.5 million maximum per year for ongoing violations. What puzzled me then, and which irks me now, is that the implication was that the doctor had to protect himself against violations and resultant hefty fines. The point that was completely missed, even inverted, is that denying a patient access to his or her records in whatever way the patient deems suitable seems like a more sure route to a violation than just providing what it is the patient requests, in the form or via the means requested by the patient.

Now that doctor’s office will fax me things like test results. Some will even (horror!) email them. And then there are others, like another one of my doctors, who refuses to provide records or results in any form other than by mail, or picking it up in person. Never mind the inconvenience of the latter choice, I would defy anyone to show me how snail mail is any less prone to pilferage or misdelivery than a fax or email. I even maintain an encrypted email account for highly sensitive information. But all that is irrelevant. The Department of Health and Human Services (HHS), which oversees application of HIPAA, is clear on the subject: A provider should email, fax, or accommodate alternative delivery means as requested by the patient. Look it up. It’s right there, explicitly spelled out by HHS, in the department’s HIPAA FAQs.

That’s really the key issue: Patients have a right to see and receive their own records and results, and HIPAA exists to protect them, not the doctor or other provider. So if a patient wants his or her bloody records emailed or faxed to them, HHS says the provider should accommodate that request. But you’d never know that from the patchwork of restrictions, most of which make little to no sense anyway, that one encounters when requesting one’s records.

Of course, all this assumes that a patient has signed a statement authorizing release of information to the patient and whatever third-party designees, if any, that the patient might include in the release. Now here is a suggestion – a strong one: Why not include a check-off box with a line where the patient authorizes positively (by checking the box) transmittal of records via email or fax? Easy-peasy, and takes care of any misunderstanding. And while you’re at it, how about another line with a check-off box authorizing the same thing for any third-party designees? Two lines, and you can sleep better at night knowing the patient has asked for this and HHS says you should give it to them. And it’s in writing, no less.

All this leads to the source of my current distemperous mood toward doctors and things medical. It’s been four weeks – not hours, not days, not business days, but weeks – that I have been requesting the results of an MRI from a certain specialist. I requested that the doctor or his nurse-practitioner call me before I left on an extended trip so I could at least have a sense of what the MRI revealed. I was told, well, he probably won’t call you. He likes to do things in person.

Well, I like to do things in person, too, when that works. But in this case, it wasn’t even possible to get an appointment in less than a month or more. And I was clear that I was leaving the state and needed the information before I went.

Ha. Fat chance. Four weeks have gone by, I’ve lost count of the number of times I’ve called this doctor’s office, had my primary care physician’s office call him, even the insurance company called the office when I filed a grievance with them over this. And still I can’t get either the doctor or the nurse-practitioner (which would be fine) to speak with me and discuss the test results, much less actually get those results. Now if ever there is a HIPAA violation, it would seem this is it. It will take a formal complaint to HHS, but that is imminent. I now even have my attorney on the case.

The doctor might have his procedures, but there are two parties to the transaction, the other being the patient, and in this case this patient has different procedures. And HIPAA is on his side.

It’s bad enough having to deal with doctors and tests and health issues without having to be put under further stress and duress by providers and offices that just throw more roadblocks and obstacles in the patient’s path.

All this seems very 19th Century to me. Doctors hold themselves up as miniature deities and patients are just supposed to accept whatever inconveniences, incompetence, or affronts that the doctor and doctor’s minions subject them to. And there are others besides those discussed here. Let’s just save my rant on the prescription system for some other time, ‘kay?

If you’ve encountered any of these issues in dealing with doctors, I invite you to tell everyone about it in the comments. And if you have a different and more positive story to tell, by all means post that, too, in the comments. And if you question the premises on which this piece is based, well, fire away with that, too.

Meanwhile, I’m going to fax this piece off to a few doctors I know (I have to fax them since I don’t have their email addresses) and maybe shake a few trees. Or else things will just go on as they always do. And watch this space if I decide it’s necessary to start naming names.

Physician, heal thyself!

From Water to Water

From Water to Water

. . . for water thou art, and unto water shalt thou return.”

Taking a little poetic license here with the wording of Genesis 3:19 to illustrate the intrinsic nature of hydrogen technology.

We’ll get to how that works, but first a little background, about me, and about hydrogen and its use in electricity-producing devices known as fuel cells.

I covered the space program as a science writer back in the 1980s, including daily interaction with NASA’s Space Shuttle program. That’s when I first started getting really interested in hydrogen as a potential fuel source for the future, including replacing fossil fuels for use in our cars, trucks, buses, and possibly even aircraft. At the time, I considered various possible fuel sources, and the one that made the greatest sense to me was hydrogen, the most abundant element in the Universe. Not to burn hydrogen as we burn gasoline or diesel, or as the Space Shuttle burned it for lift-off, but rather as a source to produce electrical energy through a fuel cell that would then drive electric motors.

NASA has been putting fuel cells aboard spacecraft since the early 1960s, and they are what generate electricity aboard many spacecraft, including the Space Shuttle when it was operational. Fuel cell technology is actually a very old one, the principle first demonstrated in 1801 – yes, 1801, that’s not a typo – by Humphry Davy. Sir William Grove, who came to be known as the “Father of the Fuel Cell,” then invented the first fuel cell, which he called an “electric battery,” in 1839. Two researchers, Charles Langer and Ludwig Mond, were the ones, in 1889, to coin the term “fuel cell,” as they attempted to produce a device that would convert coal or carbon to electricity. What is considered the first successful fuel cell, using hydrogen and oxygen with alkaline electrolytes and nickel electrodes, was developed by Francis Bacon in 1932.

It wasn’t until 1959 that Bacon was able to produce the first practical fuel cell, one that could be put to use driving equipment. Also during the 1950s, General Electric invented the proton-exchange membrane fuel cell, and in the subsequent decade NASA started putting fuel cells aboard spacecraft. The technology since then has continued to develop, evolve, and gain in efficiency, which puts us where we are today.

My conclusion 30 years ago that hydrogen, used to generate electricity through fuel cells, would be the wave of future automotive technology was not the first bit of technical or scientific prognostication I had come up with. Ever since I was a kid I saw concept after concept that I first postulated subsequently adopted by manufacturers and appear on cars as well as on ships. It’s taken nearly three decades, and it probably will take another decade to be fully realized, but I finally am seeing my conclusion about hydrogen and fuel cells coming into reality. I don’t suppose I am the only one who saw this development, but I feel increasingly vindicated that it was an accurate prediction.

Now, getting back to the water-to-water thing. If you remember anything about your early schooling, beyond perhaps your first teacher’s name or the name of your best friend, it is the formula for water: H2O. The “O,” of course, stands for oxygen, the third most abundant element in the Universe. And the “H” stands for hydrogen. Two atoms of hydrogen, combined with one atom of oxygen, give us that liquid, water, essential to life as we know it.

Now here’s the really neat thing about hydrogen. It can be produced by separating it from oxygen in water, yielding both key elements to produce energy in a fuel cell – hydrogen and oxygen – and then when they are rejoined at the end of the process, voila, you get back water, and only water. It starts as water and ends as water. Water-to-water. Neat, huh?

Compared with a standard internal combustion engine burning gasoline or diesel, which produces poisonous carbon monoxide, nitrogen oxide, sulfur dioxide, particulate matter, and other nasty stuff, it’s kind of a no-brainer. But what about pure electric car with motors powered by batteries, you ask? Aren’t they even cleaner, producing no pollution? Well, that’s only if you look at the motors themselves. But where does the electricity needed to charge the batteries to drive the motors come from? Right. Power plants which, depending on the plant, might burn fuel oil, coal, nuclear fuel, or natural gas (the latter perhaps being the cleanest source of mass power production, save for hydroelectric plants which have their own issues associated with them).

Former Fox News commentator Bill O’Reilly once waxed eloquent about how all the nation’s cars should be electric and how much cleaner that would make the environment. I pointed out to him something called the Law of Conservation of Energy, which means it would take the same amount of energy to move all those cars regardless the source of the energy, and if the source of the electricity was central power plants, as it would be, there still would be a significant amount of pollution associated with all those electric cars. Alas, O’Reilly, clearly not a physicist, chose to ignore my message.

There are other problems with electric vehicles, too, including significant environmental issues with both the manufacture of the big batteries used in cars – building an electric car produces more greenhouse gases than does building a conventional car – and their disposal when they’ve reached the end of their useful life. And while the best pure-electric vehicle today might go over 300 miles on a charge, most still are limited to a range of 100 – 200 miles. Not very far, especially when it can then take anywhere from 30 minutes for a quick charge up to around 80 percent of battery capacity to as long as 12 hours to re-charge the batteries. If you’re not in much of a hurry or not going very far, an electric car might meet your need. Otherwise, not so much.

There is another huge problem with electric cars that was highlighted in recent months by the three major hurricanes to hit U.S. shores this year: Harvey, Irma, and Maria. When power is knocked out for large swaths of territory for hours, days, weeks, and, in some cases, months, an electric vehicle becomes a very large paper weight. Lacking a source of power to recharge its batteries, an electric vehicle isn’t going anywhere once its batteries are depleted. While there usually are conventional fuel shortages around big storms, people can fill their tanks ahead of time and often there are limited sources for gasoline and diesel available before, during, and after big storms. A conventionally powered vehicle might keep going while an electric one might not.

Looking now at hydrogen cars, the cars being produced and sold that are called “hydrogen-powered” actually employ fuel cells to drive the electric motors that drive the cars. While lagging far behind electric and hybrid-electric cars in terms of sheer numbers on the roads, the biggest problem retarding their more widespread use is a chicken-and-egg conundrum centered around the availability of hydrogen fuel stations. With low numbers of hydrogen vehicles there is low incentive to provide hydrogen fuel stations, and the low number of hydrogen fuel stations deters more widespread marketing and purchasing of hydrogen vehicles. But there might be changes on the way as, I would argue, there should be.

It’s estimated that by the end of this year there will be just 50 hydrogen filling stations in the U.S., most of them in California. There also are fleet stations and those used for research vehicles, but there is a huge gap in the number of places where one can fill up a hydrogen vehicle. Consider, however, that it only takes 3 – 5 minutes to refuel a hydrogen car, comparable to filling up a gasoline or diesel car, versus the hours needed to charge an electric vehicle, and the fact that hydrogen cars have ranges in excess of 300 miles and acceleration often equivalent to a conventional car.

Besides the paucity of places to fill up, the other problem with hydrogen is how to generate it in clean and economical ways. While it’s the most abundant element, it loves to join with oxygen to make water and other atoms to form other substances, and breaking it free to run it through a fuel cell is both a technical and an economic challenge. While there is enough oxygen in the air to use in a fuel cell, it’s a more difficult proposition with hydrogen.

There are all sorts of ways used to generate hydrogen, ranging from throwing iron filings into vats of sulfuric acid, to cracking hydrocarbon molecules in natural gas to, a more recent proposal, using geothermal heat at great ocean depths to generate large quantities of hydrogen. While the first method produces toxic waste, the second produces carbon dioxide, a greenhouse gas, and the third is still under development, there is a simple, tried-and-true method, alluded to at the outset of this piece, that starts and ends with water.

That method uses electrolysis to separate water into its constituent atoms, and then after passing them through a fuel cell, reunites them as water at the end of the process. In fact, it’s relatively simple to construct a hydrogen generator of this sort – I’ve done it myself with readily available materials costing somewhere around $100 – and there are commercially available hydrogen generators for prices equivalent, or less, than making one’s own, and there even is a portable hydrogen reactor and fuel cell available for $105.99.

The basic problem with generating hydrogen through electrolysis is that it uses electricity to produce the hydrogen to be used in a fuel cell to, you guessed it, make electricity. But it’s not hard to envisage using solar or wind energy to provide the electricity used in the electrolysis. In fact, I think it doesn’t take a huge amount of imagination to picture each household with a hydrogen vehicle generating its own hydrogen. And maybe it’s a bit of a stretch today, but why can’t we see each hydrogen vehicle with its own on-board hydrogen generator, powered with rooftop solar panels, producing its own fuel from water that then returns to water and is recycled back through the hydrogen generator and, employing a little hyperbole, becomes its own perpetual motion machine?

We’ve heard of the supposed possibility of running cars on water, but with hydrogen cars this is a possibility, and it’s all based on science, not science fiction or a scam, if the technical issues can be worked out.

Elon Musk, who has put all his eggs in the electric car basket with Tesla Motors and the Tesla Gigafactory battery-production facilities, calls hydrogen technology “incredibly dumb.” He thinks it’s inefficient. But the major automobile manufacturers against which Musk and Tesla are pitted might disagree, and there are no fewer than eight hydrogen cars either currently available or under development for the marketplace in the next few years. These include the Toyota Mirai and Honda Clarity, two hydrogen cars already on the market, and hydrogen cars planned for release in the next few years by Lexus, Mercedes-Benz, Audi, BMW, Ford, General Motors, and Nissan. A small Welsh startup, Riversimple, is making its subcompact hydrogen car available in the UK this year, Ford expects to have its hydrogen car out this year, and startup truck maker Nikola Moto Company unveiled a prototype hydrogen truck late last year that it expects to offer by 2020, with a range of between 800 and 1,200 miles. Nikola also plans to open 364 hydrogen filling stations by 2019.

Meanwhile, the French firm Alstom ran its first hydrogen fuel cell train, the Coradia iLint, in Germany in March, reaching 80 kph, and 140 kph in tests run in the Czech Republic, and orders for the train are already pouring in. Its sole emissions are steam and water.

“It’s so clean you can breathe it in,” says Stefan Schrank, Alstom’s project manager of the train’s emissions. And it is 60 percent less noisy than a diesel-powered train.

Whether the various plans for hydrogen cars and other vehicles reach fruition remains to be seen. It’s still not clear whether hydrogen is the fuel of the future and always will be – as Charles de Gaulle once said of Brazil – or if it becomes the primary fuel to replace fossil fuels. The question may be decided in the next 10 – 15 years, or even sooner. It was my pick 30 years ago, and so far I’m still betting on it.

Water-to-water, baby. I think that’s a winning formula.