Dreams and Nightmares: Practical and Ethical Issues for Patients and Physicians Using Personal Health Records

Electronic health records for patients, personal health records (PHRs), have become increasingly popular among policy makers and purchasers, but uptake among patients and physicians has been relatively slow. PHRs have varying uses that might make them more or less appealing to different stakeholders. The three core uses for PHRs — promoting communication, data use, and patient responsibility — each raises a set of potential practical and financial dilemmas. But some ethical concerns are also at play, some of which are rarely recognized as values-based barriers to the use of PHRs. Recognizing these ethical issues, and addressing them explicitly in PHR design and policy making, would help PHRs to achieve their promise.     

A new barrier to participation: Heterogeneous application of voter identification policies

In democratic societies there is a tension between maximizing ballot access and minimizing voter fraud. Since the 2000 presidential election, this tension has been central to discussions about election reform at the national, state, and local level. We examine this tension by focusing on the implementation of voter identification laws in one state that has experienced significant issues in recent elections, and that is currently implementing election reform: New Mexico. We hypothesize that Hispanic voters are more likely to show some form of identification than other types of voters. Using a voter data set from New Mexico's First Congressional District in the 2006 election, we find that Hispanic, male and Election Day voters are more likely to show some form of identification than non-Hispanic, female and early voters. In addition, using an overlapping study of Bernalillo County 2006 poll workers, which almost entirely overlaps with the First Congressional District, we find no evidence that differences in poll worker partisanship or ethnicity produce differences in voter identification procedures. Our findings suggest that broad voter identification laws, which may be applied unequally, may be perceived as discriminatory.     

Atherosclerotic and Hypertensive Cardiovascular Disease are Associated with Death at Sublethal Carboxyhemoglobin Levels: A Postmortem Study

Residential fires are a significant cause for morbidity and mortality in the United States. Death is often the result of soot and smoke inhalation causing carbon monoxide (CO) toxicity. The approximate lethal level of carboxyhemoglobin (COHb) in healthy adults has been well described. However, a significant number of medical examiner cases involve infirmed decedents, often elderly, with complex cardiovascular disease burdens. It is well known that death in these cases will occur at sublethal levels of COHb; however, increased lethality has been largely documented via anecdotal experience and lacks quantification. Fifty-five cases were identified where death resulted from smoke and soot inhalation suffered in a residential fire. The control group, with no cardiovascular disease, had an age-adjusted mean COHb level of 61.6% at the time of death. Presence of hypertensive cardiovascular disease showed a 30% reduction in COHb (age-adjusted mean 43.2%), atherosclerotic disease showed a 33% reduction (age-adjusted mean 41.5%), and combined disease presentation accounted for 41% reduction (age-adjusted mean 36.3%). When controlling for age, atherosclerotic and hypertensive cardiovascular diseases were each associated with statistically significant decreases in COHb (p < 0.01). Increasing age was associated with decreased COHb levels at 2.8% per 10 years of life (p < 0.01), even when modeled with hypertensive and atherosclerotic disease. These findings carry important public health significance, as well as practical significance for the medical examiner when interpreting COHb levels in cases of suspected deaths due to smoke and soot inhalation.