By: Viji Sundaram in Mountainview, California
A much heralded push toward digital patient portals, commonly integrated with electronic health records, may be exacerbating health disparities between rich and poor, instead of reducing them, as they were intended to.
In fact, for a variety of reasons, “you could argue they increase disparities,” said Suneel Ratan, chief strategy officer of Community Health Center Network and the Alameda Health Consortium, who has researched the use of patient portals in Bay Area community health centers.
Last year, MayView Community Health Center’s three clinics – here in Mountain View, Palo Alto and Sunnyvale -- launched their patient portal tool to meet “meaningful use” requirements in order to receive federal incentive checks, a part of the Electronic Health Records Incentive Program. The program was designed to help health care providers move away from a paper-based system. A few mouse clicks allows a doctor to navigate the entire medical history of a patient.
Patient portals, which have been in use for more than a decade in larger hospitals nationwide, are commonly integrated with electronic health records. They are secure online websites that give patients 24-hour access to their personal health information from anywhere with an Internet connection. It’s a way of patients being engaged with their care team and on their own time, with the hope that it will lead to better health outcomes.
Among other functionalities, patient portals typically include online appointment scheduling, bill pay, prescription renewals and the ability to accept patient-generated data on allergies and other health issues. Patients also have access to lab results.
MayView, a federally qualified health center (FQHC), spent about $30,000 in staff time to build its portal, the clinic’s Executive Director Kelvin Quan said, noting that the tool was not only to meet the federal “meaningful use” standard by tethering it to electronic health records, but also to “meet a standard in adopting the patient care model known as ‘Patient Centered Health Home,’” a kind of one-stop shop for patient care.
Soon after MayView launched the tool, many patients enrolled, but enthusiasm seemed to wane after a few weeks, when the program became something like “white noise,” [a collection of sounds that are a mere distraction] as MayView’s Medical Director Dr. Aarti Gupta described it.
Enrollment figures in MayView’s program show that of the clinic’s approximately 6,600 patients, only 600 are currently enrolled. Of them, only 200 are active users.
Quan believes the tool’s low patient penetration is because “technology doesn’t work for our population,” a good percentage of whom are Hispanic and Asian and Pacific Islanders. That could be the reason why East Palo Alto-based Ravenswood Family Health Center, also an FQHC and with a similar patient demographic, has low usage of its patient portal – 10 to 15 percent -- according to Chief Executive Director Luisa Buada.
"The majority of our patients are Spanish-speaking with lower literacy (including health literacy, reading literacy and computer literacy) rates," said Dr. Justin Wu, Ravenswood's Clinical Informatics Officer. "Add to that the current political climate with mistrust around immigration issues and a general hesitancy to give out information or have health information online, and I think it helps explain some of the problems we've been having with patients in using our patient portal." The two clinics reflect a national usage trend that showed that Asian Americans, Latino Americans and African Americans were 23 percent, 55 percent and 62 percent less likely to register for digital personal health record access, respectively, compared to non-Hispanic whites.
First off, “many of our patients can’t afford computers. If they can, their [technology literacy level] makes it difficult for them to navigate the information,” Quan said.
For those who have the app on their cell phone, the font is so small, they can’t read it, he said.
David Lindeman, director, Center for Innovation and Technology in Public Health and the CITRIS program at UC Berkeley, believes that if some of the text were taken out of patient portals and replaced with images and videos the tool could possibly be embraced by more patients.
A study done two years ago by five academics shows why the patient portal program has been relatively successful at Kaiser Permanente, a large grouping of hospital and practices, as well as the nation’s second-largest insurer. By 2015, Kaiser had registered 70 percent of their 5.2 million patients on their portal, well above the health care industry expectation of 50 percent, according to Quan.
The bulk of Kaiser’s patient portal education material – not entirely simply written -- is geared toward white, middle-class people, who are better educated. Patients with a post-graduate education are more likely to register than adults with a high school education or less on to My Health Manager.
“You have to meet the patients where they are coming from,” said Quan.
My Health Manager enrollees can email their care team members with health questions and expect a response within 48 hours.
Most of MayView’s patients are on Medi-Cal (the federal-state health insurance program for low-income people, known as Medicaid in the rest of the nation). Some are undocumented. Care providers at the clinic are already stretched thin, Gupta said, one of the reasons why MayView’s patient portal lacks the e-mail communication functionality.
“If they had to respond to queries from their patients on the computer, it would take time away from attending to patients” who prefer face time with their providers, Gupta said.
Besides, “Medi-Cal will not reimburse them” for computer time, Quan said.
Ratan said most FQHCs don’t have the resources to implement robust functionality in their patient portals. But at least one he has worked with has deployed a patient portal that includes medical records, in addition to appointment schedules and refills.
Republished in partnership with New America Media.
Commentary by Andrew Lam in San Francisco
In America, when a source of authority says it randomly singles you out, you should always be wary.
On Monday, video surfaced of a Vietnamese American, David Dao, being forcefully dragged from a United Airlines flight departing Chicago for Louisville, Kentucky. Dao, 69, had allegedly refused to voluntarily give up his seat on the overbooked flight.
The video quickly went viral around the world, including in China, one of United’s largest markets, where it broke records for being the most widely shared video on social media. United stocks quickly plummeted, dropping 4 percent early Tuesday.
Many of the comments in China and elsewhere, meanwhile, questioned whether Dao, initially believed to be Chinese, was singled out for his ethnicity. His bleeding face is now the poster child for perceived racism in the friendly skies.
“Reflecting on my three nightmare-like experiences with United,” Richard Liu, the CEO of popular online shopping platform JD.COM posted on the Chinese site Weibo. “I can say … that United is the worst airline, not one of the worst.”
Chinese media also drew attention to an online petition entitled #ChineseLivesMatter calling for a boycott of United Airlines.
Reaction from the Asian American community has been equally swift and stinging.
“There is no justification for inflicting violence on any American who poses no physical threat regardless of race, occupation, or other characteristics,” declared the advocacy group PIVOT, which works on civic engagement issues in the Vietnamese American community. “As an organization that aims to engage and empower Vietnamese Americans for a just and diverse America, PIVOT categorically condemns United Airlines and the Chicago Police for their violent actions.”
According to reports, Dao and his wife were among four passengers selected to involuntarily relinquish their seats to make room for United employees.
In its response to the growing PR nightmare, despite a public apology, United’s CEO, Oscar Munoz added fuel to the growing fire after a leaked email was released showing Munoz referring to Dao as “disruptive” and “belligerent.”
Few in the Asian American community are buying the airline’s defense.
“How exactly were the four people selected to give up their seats on this flight? What is the method of ‘random’ selection?” asked blogger Phil Yu, better known as Angry Asian Man. “Do United computers come with a Random Passenger Removal Generator? Or does a flight attendant just take a quick glance around the plane and pick a poor sucker?”
In another online post, one gate agent wrote it is typically the agent that decides who to bump. “Usually, depending on the airline, it is determined based on the last passenger to check in for the flight.”
Reporting on the incident, Business Insider noted passengers can be “involuntarily denied boarding based on a number of factors.” These include “fare class of their tickets, frequent-flyer status, their itinerary, and when they checked in to the flight.”
Yet to be sure it is not all algorithm.
Like others, Yu believes Dao was selected in part because United staff assumed that as an Asian he would be compliant. “If the ‘randomly selected’ passenger had been a blonde white lady, and she refused to give her seat, there's no way in seven hells that these cops would have dragged her ass out kicking, screaming and bloody,” Yu wrote. “Such indignities are apparently reserved for 69-year-old Asian physicians.”
He added, “Clearly, they were not counting on this guy to put up a fight.”
by Andrew Lam in San Francisco
People take pride in the food they eat, and ethnic communities especially form and retain their identities around their traditional cuisines. What’s Italian without pasta? Or Thai without their Tom Yum Goong?
For the Vietnamese, it is, of course, pho soup, that delectable and aromatic noodle dish that has had Vietnamese fighting each other over how best to make it — northerners and southerners have their own interpretation — and pho now finds itself in a controversy over a video made by Bon Appétit featuring a white chef telling people how to enjoy the dish.
At one end, there are those who bristle at a white man telling them how to eat their own food, claiming that Bon Appétit is practicing cultural appropriation. At the other end, there are those who speak of freedom of expression — freedom to eat and cook whatever they want: it’s a free a country, and it’s all protected by the First Amendment. [The Bon Appétit video has since been pulled].
My feeling on this is a little complicated. To even get to the issue of cultural appropriation, it is inevitable that one should ask first and foremost, “What is authentic?”
If you go for back far enough, everything is borrowed. Pasta makes a national dish, but it is a combination of noodle and tomato. Marco Polo, as legend has it, brought back the noodle from China, and the tomato that makes the sauce came back with the conquistadors who conquered South America.
Vietnamese cooking has been anything but authentic if you go back far enough. Vietnam had her hands in many pots, from India to France, from Thailand to China. The Banh Mi, which now dominates the sandwich industry in the United States, is a borrowed fare from the French baguette. Yet in Vietnam, hardly anyone thinks about France when they sit down and eat their favorite dish in the morning.
Indeed, appropriation and adaptations are the survival instincts of the Vietnamese who have to deal with a long and arduous history of being dominated and colonized by one powerful country after the next. Vietnamese language itself is an almagamation of Chinese, French, Khmer and an array of colliding local tribal dialects. The same can be said of its spirituality: Atop a traditional Vietnamese altar, a visitor will find various Buddhas, faded images of grandpa and grandma, and statues of Taoist saints. This combination of Mahayana Buddhism, Confucianism, and Taoism known, as tam giao, is the result of efforts to integrate religious ideas that arrived in the country over the millennia. Ancestor worship is mixed with yearnings for Buddhist nirvana, while the temporal world is measured through the Taoist flow of life force known as the qi.
Then there is the story of Vietnam’s indigenous religion, Cao Dai, established in the mid-1920s, which goes so far as to integrate and reconcile the world’s major religions. In its cosmos it perceives Hinduism, Judaism, Zoroastrianism, Buddhism, Taoism, Confucianism, Christianity, and Islam all as human efforts to worship and communicate with the one Supreme Being. It numbers Moses, Joan of Arc, Louis Pasteur, Victor Hugo, Sun Yat-Sen, Jesus Christ, and the Vietnamese poet Trạng Trình among its many prophets and saints. Graham Greene, in his Vietnam novel "The Quiet American," called Cao Dai the “prophecy of planchette,” as its spiritualists receive messages of wisdom from the various saints in séances.
Little wonder that we would see a mixture in Vietnamese cuisine as well. In bò kho, or beef stew, to cite but one example, there’s beef, carrot, and tomato brought by the French, curry powder from India, cinnamon from Ceylon, star anise from China, and chilies, lemongrass, and fish sauce from Vietnam itself. If you feel like it, pour in a little red wine from Bordeaux and it will still work beautifully. Vietnamese cooking thrives on integrating new ingredients to achieve new balances. What is invention, after all, if not one part theft and two parts reinterpretation?
Pho, too, arguably the most authentic Vietnamese dish, didn’t come into being without the help of other civilizations. What’s almost certain is that it came from North Vietnam, specifically Hanoi, about a century ago. What is less certain is how. Seminars on the dish have scholars from all over the world arguing whether the word came from the French word feu (fire) -- as in the dish pot-au-feu -- or whether it descended from the word Fen -- Chinese for rice noodle. Star anise, native to southwest China, is used in combination with Vietnamese fish sauce to give it its distinct flavor, but French onion is also used to sweeten the broth. Cardamom comes from India but noodle is definitely Chinese. Yet in Vietnam, beef was rarely eaten until the French came in the late 1800s.
The nature of all creativity is to borrow and remake -- that is to say, transgression and appropriation. Some of today’s newly invented dishes are a marriage of various traditions, an add-on, an homage. The Chicago deep-dish pizza was once thin and simple from Naples. And if you haven’t tasted a Korean barbecue short-rib taco, popularly known as the Kogi, you must. Chased with chili salsa, kimchi and crushed sesame seeds, the Kogi is a daring invention that started with roaming trucks in Southern California but people lined the street waiting for their arrival. What is avant-garde today may very well become traditional fare tomorrow.
Having said all this, however, as a Vietnamese American, I confess to sharing that feeling of being slighted in seeing my own traditional dishes being “explained” by an “outsider.” Why? Because in the modern world, those who sell themselves off as experts while ignoring those who have been practicing their living culinary tradition for generations are committing the sin of omission. It is like having an intellectual panel on America’s diversity but the panelists are all white males. Or casting Matt Damon as the lead hero in films like The Great Wall, or God forbid, a white actress to play Mulan in the next Disney film, inserting whiteness at the center of a story when historically there was none. That insistence on being the center of someone else’s story is at once myopic and narcissistic. The lack of awareness or perhaps mere laziness of not reaching out to the other is jarring, if not damning, and that self-importance backfires in the age of social media and global consciousness.
I wonder: Would it be a lot of work for Bon Appétit to ask an array of Vietnamese American chefs known for cooking amazing pho to chime in on what makes a Vietnamese dish taste good and how to prepare it? Wouldn’t it be more wonderful if we see different interpretations of the dish but still give a nod to the living culinary culture of a people as practiced everyday?
In our world, free and full of creativity, you should have the right to make any dishes you like, and reinvent and resell it.
But at the same time, you shouldn’t be able to get away with it when you pretend to have expertise of others' cultures while ignoring the people who practice them. You should at the very least pay the proper homage, and be humble as one of the many practitioners in the tasting game -- and not claim yourself as its master.
Andrew Lam is an editor at New America Media and the author of “Birds of Paradise Lost,” a collection of stories about Vietnamese refugees in San Francisco, “East Eats West: Writing in Two Hemispheres,” a book of essays on East-West relations, and a memoir, “Perfume Dreams: Reflections on the Vietnamese Diaspora.“ The above essay was originally published in Off the Menu: Asian America, a co-production between the Center for Asian American Media and KQED, featuring a one-hour PBS primetime special by award-winning filmmaker Grace Lee (American Revolutionary: The Evolution of Grace Lee Boggs).
Under arrangement with New America Media
Commentary by Mohamad Ozeir
My name is Mohamad Ali Ozeir. My father’s name is Ali. My mother’s name is Khadija. My children’s names are Zena, Hassan, Jenan, Nadine and Sahar. I look like a typical Arab man: dark, Middle Eastern.
However, I don’t feel I owe anyone an apology for the terrorist attack in San Bernardino, California. Most of all, I don’t feel the need to condemn this carnage as an Arab American of Islamic heritage.
As a matter of fact, as a journalist and an activist, I don’t understand the whole enterprise of apologizing and publicly denouncing any crime based on ethnic or religious consideration.
Because I felt as outraged by the San Bernardino attack, as I did by the massacre at Sandy Hook Elementary School in New Town, Connecticut in 2012, by the church shooting in Charleston, South Carolina last June, and by the attack on the Planned Parenthood Clinic in Colorado Springs, Colorado, just a few days ago.
And I felt equally related to these assaults as to what happened in San Bernardino.
I wonder why we do have a debate about naming the terrorist attacks committed by people of Islamic background. While I can understand the sensitivity shown by the Obama administration toward this point, it is difficult to comprehend the right wing Republican insistence on calling it Islamic Terrorism.
What purpose does it serve, other than to slap a wide label on more than a billion people, most of whom don’t even subscribe to the religion, let alone to the politics of its fanatics?
Not the majority
I have some news for those eager to issue the label.
Yes, some Muslims are planning and striving to target Americans. Even more would be happy to see such an attack take place on American soil. And many more not only wish to see it happen, but are ready to justify it – in this category, being Muslim is not a requirement.
But these are not ALL Muslims, and they’re NOT the majority. They’re not even in the mainstream, and some would argue that they have more to do with American and Western support, training, and alliance throughout the years, than with Arabic or Islamic political influence or agendas.
And it is worthwhile to note that Arab and Muslim victims of their violence outnumber all others combined, many thousand times over.
Having said that, what does it matter? For the hate speech peddlers, especially on radio talk shows, and for the participants in the “Silly Season” called the Republican Primary, it is a ploy. It is a tool for energizing the base and motivating the supporters.
It is an old political tradition, going back as far as 1798 when the Federalist Congress passed the Naturalization Act. Back then the subject of hate was the French, and since then this country has gone down the same road more than a few times. Arabs and Muslims are the latest arrivals to the labeling circle. So what?
History repeating itself
The U.S. has proven itself capable of taking care of its own history.
Maybe David Bowers, the Democratic mayor of Roanoke, Virginia, who cited President F. D. Roosevelt in touting the idea of internment camps, didn’t learn his history well enough to know that this country considers the decision to confine Japanese Americans during World War II to be one of America's most shameful acts.
I know this, I am not afraid for my well-being, and I refuse to be boxed in fear or artificial guilt.
The one thing that I do fear is becoming a victim of a shooting, either in a mass incident or single attack.
Because with all that’s going on, the stares in public places, the never-missed “random” checks in airports, the “smart” comments and camouflaged jokes, the endless profiling - with all this heavy, discriminatory scrutiny, I find it profoundly disturbing that one right of mine remains untouched, with ironclad protection.
As an Arab American of Islamic heritage, I can buy as many guns, military gear, and ammunitions as I please. Isn’t it strange?
Re-published with permission from New America Media.
by Andrew Lam (@andrewqlam) in San Francisco
CNN recently reported that college applications from Chinese foreign students to the US sounded exactly the same.
In fact, one admission officer read a phrase in one of the applications that sent up red flags: “Insert girl’s name here.” The number of Chinese students in the United States has reached 235,597 as of 2013 but admissions officers said that “as many as one in 10 applications to U.S. colleges by Chinese students may include fraudulent material, including phony essays and high-school transcripts.”
Cheating is a worldwide phenomenon, and is a challenge even here in the United States, but in Asia it has reached near-crisis levels. Last year, riots broke out when teachers at a school in Zhongxiang, in China’s Hubei province tried to stop students from cheating. Parents fought police when they found out their children were prevented from cheating. It’s only fair that their children should cheat, they reasoned, since everyone else was cheating as well.
Can Asians think?
To do well on tests is the end point, not necessarily to learn. So much so that some years ago Kishore Mahbubani, a career diplomat from Singapore, posed this question in the title of his book,"Can Asians Think? Understanding the Divide Between East and West.” A rhetorical title surely since Asia, from Confucius down to dissident artist Ai Wei Wei (the creator of the Bird’s Nest in Beijing) to writer Haruki Murakami, abounds with philosophers, artists and thinkers. But Mahbubani does have a point: The majority of the population tends to fall into conformity and while a few are winning prestigious literary and artistic awards, the majority measures success via material gains and it begins with doing well on tests, ethical considerations be damned.
Is this a uniquely Asian problem? Intellectual laziness is a major issue here in the United States too, and students buy homework online to avoid thinking the way they download music from iTunes. But America still values those who think outside the box, originality. We immortalized Steve Jobs for his inventions. We mourn comedian and actor Robin Williams’ passing for his unique, brilliant, and fierce brand of humor. Williams invents words without thinking, jokes fall out of his lips unrehearsed and we all roar in laughter, awed by his inventiveness. The inventor, the loudmouth, the class clown, the individual with a vision, the maverick – these are encouraged still in America.
I learned to say “I disagree” to my father in English when I first came here at age 11 from Vietnam at the family table. In Vietnamese, it would have sounded harsh and unfilial (unbecoming of a filial son), and unthinkable. But the “I” fell off my tongue much easier in English. It allowed me to separate myself from the clan, the collective. It allowed me to think for myself. America encourages rebellion against the collective: follow your dreams.
Alas, back in Asia the ego is still by and large suppressed. The self exists in the context of families and clans. It is submerged in the service of shared values and ritualized language. A student raising his hand to disagree with a teacher would make a rare sight, indeed, in Vietnam, and may in fact be seen as a direct challenge to authorities. You are measured by how well you do on tests, end of point.
A professor friend of mine teaches Asian American studies at a college here in the Bay Area. Every semester she catches her students cheating, mostly in the form of plagiarism. “I said to the class, ‘three of you plagiarized,’” she once told me. “’But I’ll be nice for once. Just rewrite and slide the new midterm essay under my office and I won’t flunk you.’” Three days later, she found 11 new essays under her door upon the deadline. “A lot of them are foreign students or immigrant kids, and they are not confident with their own voice.”
When you take into account that two out of three Asians in America were born overseas, it's no wonder that even the most diligent Asian students feel more comfortable in science classes than in English literature, where raising your hand to offer opinions is not only encouraged but counts toward the final grade.
Asia has become an economic powerhouse in the 21st century. China’s economy will soon surpass those of the United States and Europe. Friends of mine in East Asia are quite proud of this fact. But to them, I often ask, “What does all that mean?” Materialism, after all, is not an ideology, it’s selfishness writ large. To create a viable civilization it starts with clear moral values regarding pedagogy, a shared sense of purpose, and a critical mass of thinkers and inventors. That is, it usually takes a lot of thinking and imagining and re-inventing for a civilization to have its sphere of influence emanating beyond its borders.
And my suspicion is that it usually starts in the classroom.
Andrew Lam is an editor with New America Media and author of the "Perfume Dreams: Reflections on the Vietnamese Diaspora," and "East Eats West: Writing in Two Hemispheres." His latest book is "Birds of Paradise Lost," a short story collection, was published in 2013 and won a Pen/Josephine Miles Literary Award in 2014.
Republished with permission.
-- Canada's economic development minister Navdeep Bains at a Public Policy Forum economic summit