Hughesair (Inflection Point)

Retired physician and air taxi operator, science writer and part time assistant professor, these editorials cover a wide range of topics. Mostly non political, mostly true, I write more from experience than from research and more from science than convention. Subjects cover medicine, Alaska aviation, economics, technology and an occasional book review. The Floatplane book is out there. I am currently working on Hippocrates a Fanciful History of Medicine and Death of the Middleclass. Enjoy!


Wednesday, March 22, 2017

Fatal Crash Ketchikan

NTSB reports the 2015 crash in South East that killed 9 sight seers from Holland American Lines as controlled flight into terrain, indeed it was controlled flight first into instrument conditions.  There was plenty of blame all around. The pilot age 64 had 1200 Alaska hours and a reputation for caution. but flew an Otter into the mountainside near Ella Narrows, Misty Fjords and Ketchikan.

There were several issues. This was a part 135 operation. The mantra for part 135 is 500 and 2, that is 500 feet clear of clouds or terrain and 2 miles visibility. There was no way given the photograph and fatal outcome that this basic regulation, meant to insure minimum passenger safety, was even partially followed. The radar altimeter was found to be shut off, with the explanation that pilots frequently disable the device because it makes a frequent noise that frightens passengers. If the warning device was set at 500', that alone would confirm the disregard of the basic flight limitation for this level of commercial flying. Ah, but this is Alaska, home of the dare devil bush pilot where Lodge pilots, not limited by the Part 135 restrictions routinely brag about flight where overcast is "down to the grass." At 64, the pilot was a bit of an oddity with only 1200 Alaska hours, maybe he was a retired airline pilot. Airline pilots are accustomed to fling high, fast, in the system and on auto pilot. Mountain flying, low and slow under the scud is new to them. That may account for reports of his poor adaptation to down drafts and "misty conditions." More than anything this was a human factors disaster on multiple levels. Additionally 1200 hours may be a time when pilots gain some elementary level of confidence about Alaska flying which can easily turn into relaxation and over confidence. Then one sees others doing it, and one is tempted too. So much for the pilot, he paid the price. This was his third flight of the day, flight time and fatigue may have played a role as well.

Unfortunately, the blame does not stop there. The weather reports are not much better than in the 1940s. NWS still reports weather in the acronyms and hieroglyphics understandable only by themselves and pilots in a flight service briefing or on the ground. Add to that the US compliance with international weather terminology reports temperature and due-point in Centigrade whole numbers, numbers representing a wider value than Fahrenheit. NWS should report the temperature due-point spread with a decimal point to the tenth, so as to more finely describe the amount of visible moisture in the air. Furthermore, and for the same reasoning, WS reports low clouds and fog as mist, with a criteria that offers an excuse to fly into mist considering mist not to violate the 500 and 2 rule. In this tragic fatality weather service bears a significant blame due to its own reporting criteria.

Not to be left out, the FAA bears a significant responsibility. For one, they have left Alaska in the dark ages of aviation with primitive third world airfields, little or no support for float or seaplane operation, and in their twice a year inspections, the PI fails to contain the local convention of routinely violating the most basic part 135 rules. Furthermore, FAA is blind to the need for Alaska pilots flying in conditions prone to whiteout and sudden precipitation of fog over a massive area to be IFR certified and current whether their aircraft is or not. The FAA approaches IFR for air taxi operations is just say no. By saying no, as if saying no the FAA will eliminate the high likelihood that 135 pilots will encounter unintended and unavoidable instrument meteorological conditions.  When mist turns into a solid fog bank or suddenly dense cloud cover, there is no way to go except up, way up. Just last week a young  man failed to survive his vertical landing near Nome because he was not instrument capable. Instrument flying is not rocket science, in fact it is very basic.

Not so basic is a particular advanced IFR maneuver from the RAF. The Chandelle will get you turned around given enough maneuvering room; however, the Ella Narrows are apparently extremely narrow, severely limiting the pilots ability to just turn around. In discussing this issue this morning with another retired 135 pilot, I recalled having learned an IFR maneuver that was perfected by the British for bombing German installations at the head of Norwegian fjords. The Brits made use of twin engine Spit Fire bombers to run in low under the cloud cover targeting the enemy facility at the head of the fjord right in the face of the steep glacier wall. The pilots would drop their bombs and immediately climb up into the cloud cover, full power, steep to the stall point, then executing a coordinated turn to the left - always to the left, still full power, dropping off to a reciprocal heading while remaining in clouds, thus executing a 180 with minimum lateral displacement, IFR in the clouds until out of anti aircraft range. I was taught this maneuver (IFR) in an A36, by one of the owners of the aircraft as a safety measure for dealing with accidental controlled flight into instrument conditions in the mountains. The maneuver somewhat resembles the lazy 8 but much steeper and a bit more abrupt, scary in concept but easy to do, at least in the A 36, I don't know about an Otter. The stall characteristics might be a bit less forgiving -- would sure scare the passengers.

The FAA once allowed 15 minutes of IFR if visual flight rules when VFR could be had within the 15 minutes on departure and the same upon arrival in event weather changed in-rout. It now requires an extensively equipped aircraft, more extensive than needed when used only for emergency or potential emergency.

The operator in Ketchikan must be saddened, but cannot claim complete innocence or ignorance. One hopes there was not a financial motive for pressing the limits. The report mentions some significant training shortcomings and surely dispatch has a duty to red-line flights due to weather if indeed the owner or chief pilot is not available. The ultimate responsibility rests with the pilot but in a multi pilot operation, there needs to be a chief.

Time spent on the ground due to weather is not counted against your life.  Please consider these comment as generic and thought provoking, I have no personal knowledge of the incident nor the terrain in question and defer any judgement to the NTSB and their superb capability and analysis.



Sunday, February 12, 2017

The Big Fix

It remains to be seen whether or not the new Administration and Legislature will/can fix the economy.

Ever since Thomas Piketty's work, economists have grasp the meaning of accumulated capital as the cause of recurrent depressions, Simply put, the accumulation of wealth in the hands of the 1% and the 0.1% -- an accumulation of capital, some 6 times greater than National Income -- denies liquidity in the consumer market, which is nearly everything. A historical truth, the hoarding of wealth exactly correlates with the great depressions of the past; furthermore, relief, redistribution, came only in the form of revolution, war, pestilence - the plague was the great equalizer - or depression itself. These disastrous redistributing events correlate also with subsequent resumption of productivity, economic vigor, growth and consumerism.

The solution to redistribution, however, remains a modern day challenge. If the government somehow confiscates the wealth, would we trust them to redistribute it back into the consumer economy? One economist suggested in his lectures, dropping money from a helicopter.

Thomas Piketty, Capital in the Twenty-First Century, proposes a global tax on capital. In truth, we could never expect that level of cooperation, and who could we trust? We can't even trust our own government not to spend it on themselves. Tax is a bad word, so two problem: how to capture the sequestered wealth and how to distribute it. It's like a game of Monopoly, 6 hotels on Board Walk, everyone broke, game over. Speculation follows:

1.Thomas Paine in his book Agrarian Justice, suggested that every person has an equal right to the natural unimproved land and thus deserves a rent for the titled and improved use of that land during each person's lifetime -- makes sense. Thomas Paine if you have not done so, deserves a careful read, ("These are the times that try men's soles, etc." articulating the argument for equality and the American Revolution.) Paine outlines a system for collecting rent from property owners, deposited in banks, accounted for and distributed to every person during their lifetime, property rent, not property tax, thus redistributing capital equitably while avoiding the capriciousness of legislators attempting to, balance the budget after the fact, and the popular resistance to taxation.

2. Social Security struggles as a pay as you go (PAYGO) system, but if funded -- something like the Alaska Permanent Fund -- it would grow at the rate of capital growth, historically 5 or 6 times the rate of National Income and provide an equitable distribution of capital earnings. A funded Social Security could be far more generous, thus shifting capital into the hands of the consumer market and affording greater support for those who need it most including seniors. One might load such a fund through fees assigned to large financial holdings in the hedge funds and shadow banking's trillions. fees rather than tax, once funded it would be self sustaining. Capital growth is far greater than income. One might further prevent a raid on such a fund by removing it from the control of congress and placing it under the judicial system, judicial for protection of the constitutional amendment necessary to establish funded Social Security.

3. Free mandatory education to the age of 21 accomplishes not only an equitable distribution of capital but a game changer for a declining culture. It's nice to think globally, but at the end of the day, if we are to leave anything at all to our children we need to clean up our act here at home. Education probably offers the greatest return for the dollar in terms of driving growth. Furthermore, education to y21 will drastically reduce the unemployment by putting the unemployed back in school regardless of age and putting unemployed youth back in school and better preparing them for the high tech jobs of the future.

4. There are 3.4 million homeless, coincidentally, approximately the number of empty foreclosed homes. One forth of the homeless are veterans, and this is not counting the number of persons living in their cars and trailers. The banks carry the empty homes on their books at full value, not fair. A radical and somewhat dangerous solution might be to judiciously declare the foreclosed mortgages fraudulent restoring the titles to the former owners free and clear. This humanitarian act alone would transfer an enormous ill gained wealth back into the consumer market not to mention restoring housing to massive numbers of people. --- Great care would be needed to separate the investment banking capital from commercial deposits, not to trigger a run on the banks and failure of the commercial banking along with the investment side, doing so in such a way as to allow the investment losses not to affect the consumer side, the taxpayer or require government bailouts.
Commercial banking may once more need to separate from investment banking; there are many additional reasons.

5. Tariff should not be a bad word; it can fund a massive re-capture of capital and allow underdeveloped countries, that have no other source of revenue, to tax imports as well. OK, free trade, but balanced trade, otherwise it amounts to Colonialism. OK, let's also tax the obscene salaries of CEOs and add a high inheritance tax as well. According to Piketty a progressive tax rate above 50% correlates historically with a lower capital to income ratio and greater economic growth.

With enormous wealth, comes enormous power, much of it is used to rig the system, manage perception, the media, political correctness, a legal and environmental structure that furthers the Oligarchy. Globalization is Colonialism by a different name, and we are the colonists, the exploited. Furthermore,  free movement of labor into our country reduces the standard of living within our borders, adding to the exploitation and concentration of wealth -- a return full circle to the class divide of per-revolutionary Europe.

Again, redistribution happened naturally though not painlessly during WWI, the Great Depression and WWII. One way or another redistribution will happen; it will be painful, and nothing less than civilization is at stake.

Tuesday, January 10, 2017


February 17th marks Rene' Laennec's 236 birthday. The inventor of the stethoscope, a professor and chest physician U of Paris, would be surprised to see his invention so widely displayed, wrapped around the neck as an iconic item of dress, and in such poor taste at that.

Sunday, August 07, 2016

Trade Deficit

To burry one's head in the sands and say all is well in this best of all possible nations is part of the political correct thinking that got us were in the first place. Tha June trade deficit, just announced comes I at 44.5 billion dollars on imports of 227.7 billion and exports of 183.2 billion. Annualized that amounts to a growing half a trillion a year. What has that got to do with the economy you ask? The media continues to insist the deficit is made up by the cheaper superior imported goods and services, but the evidence says otherwise. China's military buildup, investment banking and multinational corporations are the only beneficiaries of the deficit, not the American people. Every purchase of an imported product or service subtracts from our GDP. The GDP is the better measure of our economy, not the stock market. Economists still argue over supply side versus demand side economics. In our depressed state, the only supply and demand are China and sad shoppers at Walmart.

Free trade has some benefits: it stabilizes relations between quarlsom neighbors and it increases efficiency in a free market among more or less equal trading partners. The theory first advanced by Adam Smith in his "Wealth of Nations," compared balance of trade as a producer of wealth with Smith's theory of free trade. Published in 1776 when colonialism provided abundant cheap resources and plunder, free trade thrived between large and small colonial empires with positive results for the empires, not so much for the colonies, one of the reasons we sought our own independence. 

On the other hand, today's free trade has become a means for multinationals to exploit cheap foreign labor moving US manufacturing, the only source of wealth in Adam Smith's world, to the cheapest and most receptive foreign environment, taking American jobs and the revenue from sales with them, a new form of colonialism in which we are the exploited.

Unfortunately, both political parties support the continuation of this failed experiment, the Democrats out of a sense of Utopian idealism and the Republicans out of a sense that unbridled self interest in everything economic, unregulated and privatized, results in the higher order of good, strengthened by the struggle between communism and freedom. Paradoxically both polarized political doctrines combine to perpetuate this unsustainable fantasy that the trade deficit is overall a good thing. 

Furthermore, politics as usual now swallows up the true reality articulated by both contrarian candidates -- in the primaries -- while economists still argue over supply side economics. The American people are screaming for a solution; they see problem, the well paid politicians, and media do not. Tariffs would impose an immediate solution, raining in the multinationals and the continuing loss of wealth but with unstabilizing consequences, necessitating greater security measures and a massive rebuilding of both infrastructure, manufacturing and business.

If Ireland can do it, so can we. Ireland reports a 26% growth in GDP with a big trade surplus.

Tuesday, August 02, 2016


Why would NASA promote a human space expedition to Mars when drone programs prove so successful? And to the stars, wait a minute.
Even if the crew survives, the uncontrollable cosmic radiation seriously damages both the vascular and neurological systems. Even though astronauts return younger in relation to those they left behind, the damage is not repairable. How much better to launch a drone, robotic in every respect, with the astronaught sitting comfortably and safely behind an earthbound flight deck, nine to five, evenings and weekends at home, thus solving the human factor issue and providing easier and better engineering of the space vehicle. Without the fragile and demanding attention to a survivable habitat, there would be far less space, energy and weight demand, leaving room to perfect the mechanics of the mission, mechanics that could do more than what is humanly possible. 
No longer requiring human scale, the whole project could be miniaturized, further improving the power to weight demand, never mind cost. Robotics should be the future -- a vast improvement on space probe launches in the past.
Time lag, like a satillite phone, becomes a problem with remote control. By the time a signal arrives for a maneuver, it may already be too late. Two solutions: one artificial Inteligence, and two, quantum computing, both of which are advancing rapidly. Is it science fiction to envision quantum entanglement as a means of realtime control of a drone at great distance and to what limit? -- to the stars? Artificial Inteligence seems more likely. The earthbound astronaught might discuss strategy with an onboard artificial Inteligence, 2001 without the onboard passenger or a holograph if you must, an avatar. Nanoscale might even become feasible; someone already proposed tiny space sail capsules.

Saturday, July 09, 2016


Globalization, while built for the exploitation of emerging economies and the wealth of the American people by monopolies and multinationals and justified by utopian dreams, does indeed result in greater education of young people in those exploited countries. Meanwhile US education flounders despite efforts towards qualitative improvement. Budget cuts, permissiveness and cost shifting onto unenfanchised students takes priority over quantity. Simply put, we have more early dropouts and less. time in the class room whilst the rest of the world moves in the other direction, many examples. 

The massive ills of our society result directly from a lack of qualification for employment and lack of productive engagement, lack of education. The military promises the only secure escape from the street, but most do not qualify. Think prison population, drugs, homelessness and unemployment, education should be the solution. Combine education with health care, psych care and recovery strategies -- not socialism but survival of our culture.

Not privatized education, not K- 12, but a mandatory 4 through 21 year of age education, eleven months of the year, supplemented by a voluntary pre school. Play school 9 hours for infants of working single moms or dads would solve many problems. Unwanted and inconvenient children could benefit from abundant early positive social enteraction and love, experience an early model of cooperation, civility and later citizennship. Then, advanced education through, liberal arts, engineering, science or tech school would not only channel students through appropriate areas of student interest and talent, but also: explode the economy, reduce crime, treat drug addiction and eventually eliminate homelessness and poverty. Providing dormitories for homeless students, homeless adults while extending the education to all unemployed could end poverty while providing a higher quality motivated labor force for economic growth.

Monday, June 27, 2016

Globalization = Colonialism

Well, not exactly, today we are the exploited. Political idealism, political correctness continues blindly in support of globalization despite overwhelming evidence of its deleterious effect on our economy: flat GDP, half a trillion a year trade deficit, unimployment, loss of manufacturing, polarization of wealth, overburdening immigration as well as a national security risk due to economic weakness.

Meanwhile so called conservatives, the wealthy, minimize the damage to the rest of us claiming the unemployed are just lazy, a few lost their jobs, but over all free trade is a benefit. Big business profits from cheap foreign labor, outsourcing goods and services, avoids taxes by manufacturing offshore, and multinationals go a step further. Newfound foreign wealth in part comes back seeking secure shelter, enriching our bankers with their hedge funds, dark pools and shadow banking, indeed, furthering economic and political polarization.

Government favors globalization with a belief that it enhances stability and that trading partners will be less warlike and adhear to international laws and norms. Wlhile some of this is true, it comes at the overwhelming expense of our middle class. One can hardly call the Middle East stable, however. We have unleashed wave upon wave of refugees with nowhere to go. It will only get worse with global warming, over population, war and famin.

It is past time for us to take care of our own population, not nationalism, but survival. "None are so blind as those who will not see." Our media are like marionettes to the vested interest oh the oligarchy.


Thursday, June 23, 2016

Christine Legarde

Like another elegant French lady, La Belle Poule, (The elegant French frigate fighting off the British blockade 1778) Christine, the director of IMF calls attention to US poverty, one in seven living in poverty, unsustainable, and the polarization of wealth. Christine Legarde is the first out of this whole political season to mention productivity as a solution. Our first quarter GDP growth fell to 0.5%, just short of going backwards.
Christine suggests childcare and maternity leave to bring more women into the work force and increase minimum wage, some tax credit at the low end to encourage greater participation in the economy, but the cornel of wisdom was her call for productivity.
How few pay any attention to the antecedents of productivity. First a cheap, sustainable, abundant resource, second the human resource, then capital and entrepreneurial ability, both of which we have in abundance. It is the first two where we stumble with misunderstanding and misdirection.
Think what a flood of opportunity might come from: free bandwidth, free information, cheap energy/electricity, cheep transportation, free education and cheep communication.
No business flourishes without a secure labor force, healthy, well fed, with energy and satisfaction. To that end: free or cheap healthcare, affordable food and shelter, education, safety (better law enforcement) employment, security in retirement, childcare ( pre-school) etc. If the poor had access to the infrastructure they would no longer be pore.
We can tax the wealthy to pay their fair share for public infrastructure, but none of this will work so long as we have the colossal loss of jobs to cheap foreign labor, loss of manufacturing to inequitable trade treaties, with the resulting loss of wealth from the US economy. Monopolies dominate the infrastructure, and lost wealth accrues to the so called one percent who now control the legislative process.
There remains a preoccupation with consumption. "If people would just spend more, the economy would grow/" As things stand, if people spend more, they would just run out of money. The economy runs on velocity. Spending is only a part of the equation, it's a product if you will. How many times will money change hands over a period of time. It is more a matter of churn, of energy, of optimism, an energy you can feel on the street. Instead, our political status quo brings us tattoos, obesity, drug addiction, depression, lethargy and an admonition to buy more at Wal-Mart.
More women working in the workforce and increased minimum wage are strong boosts, but they come at a price. In good times it does not require two or more family members working to provide a living. Increased minimum wage already boosts food and restaurant prices causing a strain on fixed income seniors. As the elegant French lady suggests, we need to think productivity.


Sunday, May 29, 2016

Economics 101

The Fed goes to extraordinary lengths to stimulate the economy with very little result, thus raising questions, what is the economy and how does one stimulate it? Our economic growth barely exceeds population growth and obviously all but the very wealthy are suffering from a declining standard of living. An old tattered economics 101 text book may shed some light on the questions.
The man or woman on the street has no problem feeling the depression. Why is it that economists do not? What is the economy anyway? What is the energy that man on the street feels walking down a thriving business district in a thriving city, I'm thinking of Dublin, versus the depression felt in a manufacturing town where the plants are shut down, moved to Mexico or outsourced to China?

A text book might say, "economics is the  allocation of scarce means to alternative means," that says nothing of good economics or bad economics because the economy is the very quality of life, the standard of living. The gross domestic product, GDP, offers one yard stick for measuring the economy but falls short reflecting the quality of life, the productivity that drives the economy and the palpable feeling of energy on the street. The word product is the key. The GDP is the product of the money supply multiplied by the  yearly turnover rate, the number of times that money is spent, the turnover rate or velocity. The velocity is under appreciated and the numbers are hard to find. Divide the GDP by the M1 and you get a sense of velocity, the turn over rate, the number of times we spend and pass the same dollars from one place to another over a year's time. In good times the velocity is up around 11, in bad times, like now, it is down to like 5.

In physics E = M c squared. In economics Energy equals the GDP divided by the M1, money supply in circulation. Janet Yellen and the Federal Reserve have tried to stimulate the economy with quantitative easing pumping nearly 4 trillion dollars into the economy over seven years by way of the banking system with minimal results. The strategy does nothing for the velocity or energy side of the equation in fact velocity, i.e. energy may be lower.
           GDP       M1         E        trillions $
2016    16.49    3.2446    5.08   
2015    16.47    3.0873    5.33      
2014    16.15    2.9212    5.53      
2013    15.76    2.6414    5.97
2012    15.38    2.4586    6.26      
2011    15.19    2.1618    7.03      
2010    14.94    1.8600    8.03      
1009    14.54    1.6965    8.57      
2008    14.58    1.6034    9.09
2007    14.99    1.3711    10.93
2006    14.72    1.3849    10.63
2005    14.37    1.3869    10.36
2004    13.95    1.3025    10.04
2003    13.53    1.3025    10.39
2002    12.96    1.2187    10.63
2001    12.71    1.1824    10.75
2000    12.69    1.0896    11.65
Note that a dramatic increase in money supply drives little increase in GDP
One can hardly find any reference in government accounting for the turnover
but a dramatic decrease in the energy level of the economy, less than half since 2007
In 1998 the government stopped publishing L the factor for overall liquidity,
later they stopped publishing M3. Both would reflect the trillions sequestered in the
shadow banking, hedge funds and offshore banking; I wonder why.

Productivity drives the turnover rate, the velocity and thus the energy and the standard of living. What drives productivity? The working man can tell you, the tradesman can tell you and the farmer. 
That bring us back to chapter two. From the text book John Ise, professor of economics at the University of Kansas, a grass roots economist, Sod and Stubble, productivity comes from the land, labor, capital and entrepreneurial ability. In Kansas, land was the cheap, abundant, an exploitable resource, the abundance of virgin prairie land, sod and stubble, the resource that made our mid west the wealth producing bread basket of the world. It's more complicated now you say and indeed transportation, coal, iron, then technology and now the Internet and information serves as does land for the rich productive wheat lands.

For land substitute, a cheap exploitable sustainable abundant resource, today we think foreign labor and cheap manufacturing at the expense of US jobs and an obscene trade deficit now exceeding a half a trillion a year while ignoring our own infrastructure, energy, transportation and information grid to the benefit of legislatively sanctioned monopoly. It's like colonialism all over again. OK forget the trade deficit, focus on abundant cheap sustainable exploitable infrastructure, substance and photons, 

With the second key factor - we are doing just as bad - labor, think human resource, shelter, security, nutrition and education. There are 3.4 million homeless, incarceration and a breakdown in our legal and policing systems, near poorest nutrition of developed nations and an education system at the expense of our not yet enfranchised children, legal dropouts at 16. No business succeeds long term with a total disregard for employee welfare. A nation is no different. Stop exploiting humans and free up legitimate resources for exploitation.

Building the infrastructure, freeing up monopoly based resources and providing affordable higher education and health takes care of our two most distorted and neglected factors of production, unlocking these two basic factors will release a tsunami of productivity because we have lots of venture capital and entrepreneurial ability to supply the rest, the other two.

Saturday, February 27, 2016

Medical Records, EHRs

My job entails reading and summarizing numbers of clinical records. Most of them are VA and Tri Care computer generated printouts. Gleaning useful and valid information is a challenge. The printouts often lack a date of entry. They do, however, contain vast amounts of data regarding social,environmental and immunization information. It is difficult to determine which content is generated by a physician. Many designated contributors have no identity or an array of non M.D. acronims following their name. There may be pages between credible clinical notes about the patient's current condition. The most troubling EHR data is the Problem List without dates. There is begaining date to the problem and no date of its resolution. Without a date of origion, there is no way to tell who entered the problem or when. Was it a physician, or the patient stating the problem as a diagnosis to a team member not qualified to enter a diagnosis. Then too, without a date of resolution, one cannot determine if it is a chronic problem or one long since resolved. Furthermore, without a date the reader cannot find the data supporting the stated problem. Despite modern confidentiality rules, these problem lists are used to make various determinations of eligibility. 

Much is written about the burden of the EHR on physician's time and the quality of the record. The EHRs are enormously expensive. They are competitive. There are many companies competing for the business. They all attempt to provide the federal requirements of meaningful use with a promise of standardized data. However, in so doing, the already standardized professional expression of patient data is lost.  While the bean counters may relish the access to the data they perceive as meaningful, the information critical to patient care, continuity of care and communication between physicians is lost. There is probably no turning back, but it would seem that voice recognition with streaming physician narrative would go a long way to improve EHRs. If a problem oriented record is to be the standard, Problem Lists should be by physician input only and dated by onset and resolution. Furthermore, when multiple problems lead to a single diagnosis, there should be a simple way to edit the change or at least document the thinking. As it is, there is a lot of garbage in the system.

Clinical Genomics

The goal from my perspective would be, synthesis of the entire human genome on each of my patients with a realtime, ongoing statistical correlation between his or her genome and that person's ongoing experience with the environment, disease and longevity, known correlations with disease as well, but those existing correlations cannot be trusted due to the distorted data from insurance claims and the attempts to match individuals to a population at large. 

Legislators in their ignorance or vested interest stipulate that medical records may be destroyed after seven years or less, in some cases three. Administrators too are anxious to rid themselves of the burden of data collection and storage for both financial reasons and the burden of liability. What you can not prove is hardly actionable. A single clinician over the course of his or her professional lifetime collects some 30,000 to 50,000 clinical records, a group of physicians in a group practice obviously many more. Furthermore, groups perpetuate long beyond the life of the origional physicians creating a vast and priceless database of credible clinical information relating closely to the individual and a narrow geographic location. By contrast, massive clinical data thus far comes from customer questioners, such as from 23 and Me,  or insurance data which is so distorted as to be near meaningless.

The advancement and benefit to patient care as well as a quantum leap forward in our understanding of the causes of disease seems obvious. The rapid, affordable, access to the whole human genome makes up the other side of the above equation. So far that has been only a dream frustrated by  beaurocracy, inertia and a steep learning curve. Competition, Silicon Valley and inventiveness, however, work miracles. Unfortunately, free enterprise, the very driver of innovation, now threatens the access and developement of an affordable, rapid whole human genome device. Ilumina is suing Oxford Genomics, once a strategic partner, over patents to a promising nanopor technology, a sad developement that may significantly delay the dream. Fortunately, there are other competors knocking at the door. Hopefully, Moore's Law will prevail.

"The Oxford machines will be configured as scalable computer clusters, so that new ‘nodes’ can be added to them, so that users can customize the machines. The initial system will feature [a] nodes containing 2,000 nanopores that can read DNA at a rate of hundreds of kilobases per second, the company said. Next year, the company will begin selling nodes containing 8,000 nanopores; 20 of these combined would theoretically be able to sequence an entire human genome in 15 minutes, says Gordon Sanghera, Oxford’s chief executive." From Nature Feb 25  
Erika Check Hayden