The Good Old Days

by Dr. Edwin Leap, MD, FACEP

I’ve been reminiscing about the ‘good old days’ of medicine.  I think about those times because I remember when medicine was focused on the sick and when practice was challenging & exhausting, but at its heart…fun!  So what changed?  Lots of things.  But two things in particular come to mind: EMR and HIPAA.

First, let’s discuss EMR, or Electronic Medical Records.  Where once we used paper charts or simple dictation to record information on patient care, now hospitals and physicians are increasingly forced into purchasing and using expensive and complex computerized record-keeping systems.  This was a growing trend already, but the Affordable Care Act made it all but mandatory, with rewards for implementation and fines for noncompliance.  Many small hospitals and practices, in fact, struggle to pay for the cost of implementation even as EMR companies make vast amounts of money.

I’ll ‘render unto Caesar’ here.  Paper systems are problematic.  The can be illegible.  On paper, written by hand, it is difficult to document complex medical encounters and procedures.  And thus, the next clinician involved may have trouble understanding what happened before.  (As will the attorneys in malpractice suits.)  Finally, hand-written charts lose charges and are often down-coded in billing when insurers can’t find the information they need, or find enough information to generate a proper bill.  Paper charts aren’t perfect. Likewise, dictated charts, while better, have longer turn-around times.  But both are faster and generally make physicians happier than the monstrosities that are modern electronic medical records systems.  

Indeed, to give credit where credit is due, electronic systems capture lots (and lots, and lots) of data.  And they can be helpful in retrieving information from previous visits.  And some use voice recognition dictation programs.  This kind of real-time dictation can be helpful.

And yet…EMR sucks the fun out of medicine.  Because EMR systems leave clinicians slaves to the keyboard.  The sound of modern medicine is the sound of typing.  And the great anxiety for physicians, and nurses, is the terrible tension between doing the thing we love, which is patient care, and doing the thing our employers mandate, which is hour, upon hour, of mind-numbing data-entry, all the while trying to move patients in a way that provides the best satisfaction scores and the lowest wait times.  

EMR are rarely designed with clinicians in mind. So, while the flow of the log-ins, clicks, drop-down menus, signed orders, time stamps, discharges and all the rest make perfect sense to programmers, billing companies and data-collectors, it’s an electronic nightmare for those of us who simply want to get back to our patients.  (The commonly told joke is that physicians are the highest paid data entry clerks in the country!)

In the end we care for the sick and let the charts pile up.  We then end up with ‘in baskets’ or ‘to do lists’ filled with hundreds of clicks and signatures that we have to do on our own time, after shift, to satisfy the appetite for information that administrators and government agencies desire, even when little of it contributes substantively to the care of the sick, injured and dying before us.  And woe-betide those who are delinquent in completing records!  E-mails and threats will abound until they are completed.

Older physicians and nurses, less computer savvy, sometimes simply leave.  They retire, taking their incredible skills and knowledge with them.  Younger physicians and nurses are frustrated, but have no other option except to press on and type away, longing for the bedside and the people they spent years learning to treat and comfort.

What about HIPAA?  The acronym stands for the Health Information Portability and Accountability Act. Passed in 1996, among the goals of this federal legislation is the protection of the confidentiality of patients’ private medical information.  Like so many things the government touches, it had a noble intent.  But now it is less a law and more of a bludgeon.  

Currently, in order to protect privacy, patients are yearly advised of their HIPAA rights and expected to sign forms to that effect.  And physicians are constantly beset by log-ins and passwords.  This may seem like no big deal.  Every computer has a log-in screen!  In fact, plenty of applications exist to store all of our various and sundry passwords for our many programs and devices.  However, the average physician will have a log-in and password for the hospital computer system, then for the electronic medical records (EMR) system and a separate set for the radiology system. And if a physician works in more than one facility, the number of log-ins and passwords just keeps climbing.

Our nurses have a similar burden of logging into EMR computers, but also have to access the medication dispensing cabinets which are password protected.  Taken together, it’s very difficult to move patients quickly, chart effectively or maintain a train of thought because we are constantly accessing computers and trying to remember new passwords.  (Biometrics like fingerprint scans and others might help, but we’re not there yet.)

Furthermore, HIPAA terrifies every clinical staffer because they are warned, over and over, that violating privacy is a federal issue.  Even innocently handing the wrong instructions to the wrong patient can be a huge problem.  To make it worse, clinical employees of a hospital can be fired for simply looking up their own labs.  (Their own labs!  In other words, protected from their own prying eyes!)  Their privacy ensured, their job terminated.  

And where we formerly handed lab and x-ray reports to patients so they could take them directly to their physicians, now they must go through the medical records office the next day or later to obtain what is, in fact, their own information.  (Again, protected from their own snooping.)  Or they must have their physician’s office request them with the appropriate release of information signed.   

And when we, the physicians who cared for a critically ill patient, transfer them to another hospital, it’s pointless to check on their progress.  ‘Hello, this is Dr. Leap and I transferred Mrs. Howard, the multi-trauma yesterday after intubating her and placing a chest tube.  Can you tell me how she’s doing?’  ‘All we can say is that she is in the hospital.’  Great.  That’s good quality control, to be sure.

HIPAA has indeed protected privacy (except of course for instances of computer hacking or carelessly placed and lost computers…all too common).  But it has also created a vast industry of programs and consultants, and left clinical and clerical staff slower, and more anxious, than ever.

No, things aren’t what they used to be.  Many issues conspire to make modern medicine difficult; an aging population, complex diseases, rampant addiction, resistant infections, high costs, high expectations and many more.  In the end, however, HIPAA and EMR reflect a common core issue, which is the disconnect between the administrative and political forces that govern medicine (and stand to profit mightily from supervising it) and those who day in, day out, must practice it in the presence of living, bleeding, hurting, dying, fearful human beings whose bodies have no password, and who care less about privacy than survival.

And until that chasm is bridged, it’s unlikely that medicine will ever again be as fun as it was before.  But I can imagine, can’t I, a shift without a computer and a chart without a log-on screen?  Ah, ‘to sleep, perchance to dream…’

Logging off….

   

Edwin Leap, MD, FACEP

Dr. Edwin Leap is a happily married father of four children in the process of becoming adults. He practices emergency medicine in the southern Blue Ridge Mountains.  In addition to his career in medicine, Dr. Leap writes monthly columns for the Greenville News, Emergency Medicine News and The South Carolina Baptist Courier.  He also blogs at www.edwinleap.com/blog.  From faith to family and from culture to medicine, he covers every topic with humor, insight and compassion.

Panama and the 1%: Shell Games, Taxes, and International Law

By B. Lana Guggenheim

The Panama Papers, as the information leak from a law firm operating in Panama has been dubbed, is the largest information leak in history, clocking in at 11.5 million files, about 2.6 terabytes of data, which is most likely the bulk of law firm Mossack Fonseca’s database, if not its entirety. The well-known Wikileaks cache comparably is much smaller, but is still substantial at 718,000 documents. This event has blown open the operating procedures of offshore tax havens, money saving schemes for the extremely rich, and their less than savory ties to many families, government officials, and rogue regimes all over the world.

Though the story broke only days ago, Mossack Fonseca has been setting up shell companies to shelter funds for decades, and journalists have been poring over the data for months before they released the story. While an anonymous source tipped off the German newspaper Süddeutsche Zeitung, the data they received soon outpaced their ability to process, and they reached out to the International Consortium of Investigative Journalists, consisting of a team of over 400 journalists in over 100 countries, to help. Even so, going through this much data took months.

The results have been immediate and dramatic. Already on Tuesday, the Prime Minister of Iceland, Sigmundur David Gunnlaugsson, tendered his resignation due to he and his wife having been among the many clients who parked their cash in a Panama shell business, Wintris. Considering the scars from the country’s recent financial collapse and painful rebound, there was little tolerance from Iceland residents for their premier's secret money stash, and one tied to the failing investment banks from 2008 at that - which meant there was an enormous and undisclosed conflict of interest. More than $2 billion has been traced to Vladimir Putin and his associates in Russia, and Ukrainian premier Petro Poroshenko, sole shareholder of Prime Asset Partners Limited (PAPL), has come under fire for similar reasons. The candy magnate promised to sell his business when he took office, but Mossack Fonseca set PAPL up as a shell company based in the British Virgin Islands in August 2014, at the time of Russia’s bloodiest attacks on Ukraine, thus saving him millions of dollars in Ukrainian taxes and prompting some to wonder if his priorities were the country he leads or the finances he promised to liquidate. High ranking families in China’s Communist Party are under the lens as well for quietly squirreling their wealth away, and the US and UK don’t have their hands clean either, one client being the late father of British Prime Minister David Cameron. Even Nawaz Sharif, Prime Minister of Pakistan, is under fire, as is the monarch of Saudi Arabia, King Salman bin Abdulaziz bin Abdulrahman Al Saud, and even two cousins of Syrian dictator Bashar al-Assad, Rami and Hafez Makhlouf, among many others all around the world, and in various positions of power.

But how does it all work? One commenter on Reddit charmingly described the issue behind the Panama Papers as people stashing their piggy banks in someone else’s house to hide their savings from their moms, and while some were simply seeking privacy, others were hiding stolen money and engaging in other illegal and unethical activities (you can see it illustrated here.) The reality is slightly more complicated - in order to hide their funds, corporations create new bank accounts and new business ventures based in countries that have low tax rates and/or do not tax on income earned abroad. Such havens include the Cayman Islands, the British Virgin Islands, Luxembourg, Ireland, Panama, and yes, the United States, which is in fact one of the biggest tax havens for foreign money. Ironically enough, the United States holds other countries to a standard of transparency that it does not itself follow, as the USA did not sign on to OECD standards, though Panama did, though with conditions. Because these accounts are held under different names, their origin is hard to trace, and because these countries do not disclose the information to the corporations countries’ of origin, it is easy to avoid disclosing the true extent of one’s assets and thus avoid taxation on it. Banks often seek out relevant law firms, like Mossack Fonseca, on behalf of their clients to complete these services. (Mossack Fonseca created about 200,000 of these offshore entities.) The law firms charge a fee to set shell companies up and maintain this legal fiction, but this fee is often significantly less than the home tax rate rich individuals and corporations are looking to avoid by engaging in this practice. And a legal fiction it is: one building can be home to thousands of companies and accounts that are little more than a mailbox with a gilded name plaque, with no rooms or employees to speak of. But it’s one that allows many to dodge the tax man in a way that beggars belief.

The entire situation is a tangled web of how the top tiers of international finance are open to the rich, but not the average citizen. The offshore banking industry intersects with criminals, terrorists, corporations, and your average billionaire, and often enough, it’s legal - though not always. Academics estimate that about $7.6 trillion is held in overseas tax havens, costing governments a minimum of $200 billion a year in lost tax revenues. Tax havens are an ugly, but integral part of the global banking system. However, not everyone involved in offshore banking is a thieving criminal. Some folks place funds in tax havens totally illegally, but for reasons most of us would support, such as in defiance of authoritarian governments seeking to crack down and restrict potential actors that would upset their monopoly on power.

Mossack Fonseca offices in Panama City. From elcambur.com.ve

Much of Mossack Fonseca’s work isn’t for humanitarian or anti-authoritarian reasons, however. Though the two men behind the firm, Ramon Fonseca and Jurgen Mossack, insist they are the wronged party for having been hacked into and their privacy violated - and they have a valid point - they say that their business is like “selling cars”; they are not responsible if people use their products to do wrong. Still, a number of their clients are involved in some shady business. And while technically their law firm violates no Panamanian laws, among their clients are those placed under international sanctions, and those who have earned their funds through extralegal means. Some of these companies were based in Iran, Zimbabwe, and North Korea, including DCB Finance, which had links to North Korea’s nuclear weapons program. Even in cases when they were not yet sanctioned when Mossack Fonseca helped set up their shell companies, the firm continued to act as a proxy for them after sanctions were put in place. In the case of DCB Finance, Mossack Fonseca continued relations with them until contacted by the British Virgin Islands authorities in 2010 inquiring about a different North Korean company, after which Mossack Fonseca resigned as agents for DCB Finance. They also set up a shell company that hid the millions gained from the infamous 1983 Brink’s-Mat heist at London’s Heathrow Airport, dubbed “the crime of the century.” The company in question, Feberion, was set up a mere 16 months after the crime for the London-based money launderer Gordon Parry, who went to jail in 1992 for his role in the aforementioned robbery, and Jurgen Mossack was aware that Feberion was involved in laundering money from the heist, though the law firm later denied this when pressed. And yet, they only ended relations with Feberion as late as 1995.

The pressure is on, not just for this law firm, but for the various global tax havens to engage in greater transparency and close these legal loopholes. But international banking is likely to face some fallout as well. Banks have already faced an uptick in scrutiny, and are likely to be faced with more, as well as additional regulation and even fines. Untangling the industry’s many offshore entities would also be expensive and traumatic, and would make repairing any reputations difficult, even for banks that claim they weren’t involved in such activities in the first place. Some banks have already begun to overhaul their internal structures. HSBC sold their Panama bank in 2013, and Credit Suisse sold its Gibraltar and Monaco private-banking operations. Some tax havens are also becoming more transparent, as the OECD’s original blacklist of “uncooperative havens” has significantly dropped over the past decade, though Panama, Liechtenstein, and Barbados were still named as such on an EU list last year. Closing all these tax loopholes is going to be a long, messy process, and it is likely that inventive accountants will find new areas to exploit for future clients. But one lesson everyone can learn, from tax accountants to lawyers, is that cybersecurity will be an increasingly significant factor. Leaks this big only happen if someone scrapes the entirety of a database, a security breach that is the stuff of nightmares.

Cited Sources and Further Reading

Beauchamp, Zack. "The Panama Papers Revealed Lots of Shady Stuff. But Some Shell Corporations Aren't so Bad." Vox. Vox, 05 Apr. 2016. Web. 06 Apr. 2016.

Bilton, Richard. "Panama Papers: Mossack Fonseca Leak Reveals Elite's Tax Havens - BBC News." BBC News. BBC, 04 Apr. 2016. Web. 06 Apr. 2016.

Chang, Alvin, and Javier Zarracina. "The Panama Papers Leak, Explained with an Adorable Comic about Piggy Banks." Vox. Vox, 04 Apr. 2016. Web. 06 Apr. 2016.

Clark, Nicola. "How a Cryptic Message, ‘Interested in Data?,’ Led to the Panama Papers." The New York Times. The New York Times, 05 Apr. 2016. Web. 06 Apr. 2016.

Cox, Simon. "Panama Papers: Mossack Fonseca 'helped Firms Subject to Sanctions' - BBC News." BBC News. BBC, 04 Apr. 2016. Web. 06 Apr. 2016.

Díaz-Struck, Emilia, Et Al. "Panama Papers: Who's Who?" The Irish Times. The Irish Times, 04 Apr. 2016. Web. 06 Apr. 2016.

Drucker, Jesse. "Panama Has Company as Bank-Secrecy Holdout, as U.S. Offers Haven." Bloomberg.com. Bloomberg, 05 Apr. 2016. Web. 06 Apr. 2016.

Fitzgerald, Alison, and Marina Walker Guevera. "New Leak Reveals Luxembourg Tax Deals for Disney, Koch Brothers Empire." International Consortium of Investigative Journalists. International Consortium of Investigative Journalists, 09 Dec. 2014. Web. 06 Apr. 2016.

Gardner, Matthew. "Panama Papers and America's Problem." CNN. Cable News Network, 05 Apr. 2016. Web. 06 Apr. 2016.

Garside, Juliette, Holly Watt, and David Pegg. "The Panama Papers: How the World's Rich and Famous Hide Their Money Offshore." The Guardian. Guardian News and Media, 03 Apr. 2016. Web. 06 Apr. 2016.

Golshan, Tara. "The 8 Most Important Things to Read to Understand the Panama Papers Document Leak." Vox. Vox, 04 Apr. 2016. Web. 06 Apr. 2016.

Karmanau, Yuras. "Ukrainian President Under Fire Over Panama Papers." US News. Associated Press, 04 Apr. 2016. Web. 6 Apr. 2016.

Kroll, Louisa. "Panama Papers Fallout: Iceland's PM Resigns, Ukraine's President Pressured, Billionaire Responds." Forbes. Forbes Magazine, 5 Apr. 2016. Web. 06 Apr. 2016.

Maven, Duncan, and Lionel Laurent. "Banks Have a Panama Problem." Bloomberg.com. Bloomberg, 04 Apr. 2016. Web. 06 Apr. 2016.

Mullen, Jethro. "Panama Papers: Rich and Powerful Respond to Claims They Hid Billions Offshore." CNNMoney. Cable News Network, 04 Apr. 2016. Web. 06 Apr. 2016.

Nelson, Libby, and Zack Beauchamp. "How the Panama Papers Brought down Iceland's Prime Minister." Vox. Vox, 05 Apr. 2016. Web. 06 Apr. 2016.

"Panama Law Firm Says Document Leak 'a Crime'" RTE.ie. AFP, 04 Apr. 2016. Web. 06 Apr. 2016.

"Panama Papers: How Did Panama Become a Tax Haven? - BBC News." BBC News. BBC, 05 Apr. 2016. Web. 06 Apr. 2016.

Politi, Daniel. "The Latest From the Panama Papers: Details From the Largest Leak in History." Slate. Slate.com, 05 Apr. 2016. Web. 06 Apr. 2016.

Ryle, Gerard, Will Fitzgibbon, Mar Cabra, Rigoberto Carvajal, Marina Walker Guevera, Martha M. Hamilton, and Tom Stites. "Banking Giant HSBC Sheltered Murky Cash Linked to Dictators and Arms Dealers." International Consortium of Investigative Journalists. International Consortium of Investigative Journalists, 08 Feb. 2015. Web. 06 Apr. 2016.

Schmidt, Blake. "Panama Papers: A Conversation with Jurgen Mossack and Ramon Fonseca." The Sydney Morning Herald. The Sydney Morning Herald, 05 Apr. 2016. Web. 6 Apr. 2016.

Schmidt, Blake. "Panama Papers: Jurgen Mossack Says the Cat's Out of the Bag." Bloomberg.com. Bloomberg, 04 Apr. 2016. Web. 06 Apr. 2016.

Schmidt, Michael S., and Steven Lee Myers. "Panama Law Firm’s Leaked Files Detail Offshore Accounts Tied to World Leaders." The New York Times. The New York Times, 03 Apr. 2016. Web. 06 Apr. 2016.

"Tricks of the Trade." International Consortium of Investigative Journalists. International Consortium of Investigative Journalists, 05 Nov. 2014. Web. 06 Apr. 2016.

Wayne, Leslie, Kelly Carr, Marina Walker Guevera, Mar Cabra, and Michael Hudson. "Leaked Documents Expose Global Companies' Secret Tax Deals in Luxembourg." International Consortium of Investigative Journalists. International Consortium of Investigative Journalists, 5 Nov. 2014. Web. 06 Apr. 2016.

How to Increase Your Profits for Free with Enky

On this blog, we’ve been talking a lot about what Enky can and will do for professionals across the country. What we haven’t discussed are all of the benefits Enky will bring to the professional education industry, especially those independent course providers that make up such a large portion of the current system. We aim to fundamentally change the way professional education works, but these changes will not only be beneficial to course providers individually, they will lead to overall growth in the industry space as a whole.

The primary benefit we can offer course providers is our laser focus on the most important thing to them: their bottom line profits. Unless a provider so chooses, they do not pay Enky a dime unless a course of theirs actually sells through the Enky marketplace. By ensuring that the only costs to providers are directly driven by sales & collection of customer cash, Enky removes a significant portion of the risk related to marketing and promoting of individual courses as well as the overall provider brand. We take care of the customer acquisition, all providers need to do is create the quality content that professionals have come to expect from educators today. For providers that would like to promote themselves further within the Enky marketplace, we build custom marketing plans that will help drive targeted professional groups to the courses on offer. Through these initiatives, Enky can assist with many of the problems that today’s course providers might face, including low registration figures for live courses (both online & in person) & directing traffic towards more profitable or desirable courses.

Another benefit Enky’s marketplace system provides is the offloading of the significant cybersecurity risks that come along with credit card processing & data collection & storage in the modern age. We live in an era of increasing cyberterrorism & hacking attacks meant to steal personal & professional data, including credit card numbers, professional license information, & address information. Course providers should not be in the business of safeguarding this valuable data, as there is no need for companies & universities that focus on education to be liable in the case of a catastrophic data breach. Thankfully, here at Enky, safeguarding important data is a critical part of our business & we would be more than happy to take the risk out of the hands of course providers. We also handle the other aspects of business, including direct marketing & information processing, so that providers can focus on what they do best: educating the next generation of successful professionals.

Finally, we use our emphasis on data & information collection & processing to deliver cutting-edge analytics that allow course providers to improve their decision making. By changing raw data into usable business intelligence, we can bring unseen trends to life. We analyze the buying & browsing habits of the entirety of our user base to generate important insights that help identify trends in education, courses that are underperforming, & profitability of courses & marketing campaigns. These analytics are delivered directly through the Enky platform & can make the difference between a profitable year & a year of losses.

We strive to make professional education better for all parties, learners & educators alike. We look forward to working with a wide variety of providers from all manner of professions. If you are a course provider & are interested in working with Enky or learning more about the platform, please email me directly at mcote.enky@gmail.com . I would be more than happy to answer any questions, alleviate any concerns, or just have a conversation about the professional education industry. We are excited to work with any & all course providers to bring the hard-working professionals of the United States the quality educational content they are searching for.

Yours truly,

Mike Coté
Enky, Inc. CEO/Co-Founder