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#just out like that to spook anyone that i intentionally tried to AVOID spooking
digimonloving · 2 years
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omg are we doing halloween requests? 🥺 can i request some hcs for impmon, kotemon, and lunamon on halloween night ? how would the trio be celebrating the holiday individually? 👻 would they stick with their tamer(s) or scare other kids/digimon on the streets?
Impmon
Impmon takes to wanting to spend an hour or two scaring people. It's the one day he gets to do it and it's accepted! Sure, some kids don't run or they let out a scream and then laugh since he's just a tiny lil guy, and can be passed for a kid in a costume if people don't look hard enough at him. He thinks it's more funny when people run, though. He tries to avoid scaring anyone who has Digimon, since he might find himself strong but... best to not test it all that much.
After he had his lonesome fun, if his own Tamer is out and about he's going to be joining their side, with a bag of candy of his own that he may or may not have taken from one kid he scared a bit too much to where they dropped their candy and ran. Ah well, more candy for them, yknow!
Kotemon
Kotemon does as his Tamer does. He sits with them, carving pumpkins or generally messing about, and when it comes time to get ready for trick or treating, he's basically already set with his own outfit, so they needn't worry over him.
He very much sticks by his Tamer's side, following after them and joining in whatever they do. He doesn't find any joy in scaring others, at least not intentionally. Considering his glowing eyes and his quiet nature, he might scare one or two people on accident...
Lunamon
Lunamon is a sweet Digimon, she couldn't scare anyone even if she tried. Even if she does look like a little ghost when looked at in a specific way. But that face! She's too happy and cute to be able to spook anyone at all.
She very much sticks by her Tamer, and tries to keep them out of trouble. She slightly scolds them if they decide to scare others, but if it's simple night of going house to house, she follows by their side and makes sure that they keep on their planned way and don't get lost.
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batfamscreaming · 3 years
Text
[superbat hs au - Court of Owls, First hints of ~superpowers~
Tommy was willing to fill the time a while until supper, when about ten minutes before six, the boy on the top bunk would finally sit himself up and slide down to the floor and tugging on shoes without much of a word. “Almost six. Get ready to go.”
--
“Uh-”
Clark had asked him if he had any family, and what he planned to go to college for, and other generic questions he could manage to think of while he unpacked his things and then shoved his empty luggage aside.
“Six?” He asked, like he hadn’t heard any of what Harvey said before.
--
“Dinner,” Bruce said as explanation, unbothered.
(“Unfortunately, my mom,” Tommy had said with a roll of his eyes. “And obviously, Bruce’s an orphan. I’m hoping for medical school, to be a surgeon. What about you?”
There was no moment to acknowledge the middle part of the sentence. Only an impossible-to-hear tightness in the boy in the bunk’s otherwise steady breathing. And then it was gone again.)
“They’ll want you to wear something nice for the opening dinner, and any dinner on Sundays. If you don’t have anything else, your school uniform will do,” Bruce said.
--
(“Wh- journalism.” Clark had replied, but didn’t dare ask about how Bruce was an orphan.)
“Oh, okay. Uh. Yeah. I’ll have to get changed then.” Clark said, and dug around for his uniform. He didn’t have anything nicer than that with him.
He walked out to head to the bathroom and change.
--
“Alright.”
They would wait for him to return.
When he did, it was clear Tommy had changed clothing too, though he hadn’t bothered to leave the room to do so. He sat with Bruce on their bottom bunk, dressed in a matching oxford and button down jacket. Dark pants, black shoes. They could’ve been siblings, probably, despite their personalities.
And once all three were there, off they went, Bruce dutifully leading the way to the cafeteria, and Tommy trailing a bit behind him, content to just follow along for the moment.
“Sundays and special dinners we gotta eat with our hall table,” Tommy said. “And listen to the headmaster give speeches. But other than that, school’s pretty great.”
--
Clark followed along behind them. The closer they got the louder things got, and he could tell this was going to be rough. Places that were loud even for regular people were killer on him. It was so hard to focus on what you were supposed to.
“You like school?” He asked, sounding a little in disbelief.
--
“Uh, yeah?” he said. “Get some time away from the family? Live with my best friend? School rocks.”
He slung an arm around Bruce, and it was accepted with a huff.
“Not everyone’s as good at school work as you,” Bruce said.
“You are, though,” Tommy said. “So you don’t get to point that out to me.”
He poked Bruce’s cheek. The quiet boy smiled a little.
--
Clark didn’t say much. He felt like a third wheel, and the black-haired kid really wasn’t much of a talker. Couldn’t blame him if he really was an orphan.
The dinner was… boring. But hey, free food. The headmaster talked about the upcoming year and how they were all going to grow into strapping young, disciplined men and yadda yadda. Clark didn’t really pay attention.
When dinner was over it was back to the room. Back to bed.
… He had a hard time sleeping. Gotham at night was still so damn loud compared to back home.
--
Gotham was loud.
So were the dorms.
(someone, somewhere in the building, was crying into their pillow. Trying to muffle it, but the dissonance--
Multiple people were. Quiet, muffled, hiding it--)
In His Room.
In his room, the first night, a heart started to rocket up in pace from where it had once been steady, panic--
Bruce on the top bunk jerked awake, with the sound of his teeth biting through his lip to keep quiet.
--
Sometimes Clark didn’t realize what was supposed to be loud to normal people and what wasn’t.
“... You okay?” He whispered out into the dark.
--
The boy flinched.
….rolled over to face Clark, breathing still shallow.
He flinched again at whatever he saw.
“...fine,” he said. Then, “Quiet.”
--
His eyes were still bright in the dark, but only when they caught the light.
“... Okay.” He said, and wouldn’t say anything else.
He wouldn’t get much sleep.
--
It was something Clark couldn’t hear, but Bruce’s mind wouldn’t quiet anymore than Gotham or the dormitory would.
“...what’s with your eyes?” he whispered.
--
Oh damn. Oh shit.
He quickly closed them and rolled over so he faced away from the other bunk.
“Nothing.”
--
There was a disbelieving huff from the other side of the room.
...unfortunately, Clark wasn’t the only light sleeper.
“...mmh?” Tommy mumbled, splayed out on the bottom bunk. “What’s goin ‘rong?”
--
“Nothin’.” Clark said again, and didn’t turn around.
They had sent him here to get away from everyone knowing what he could do. He couldn’t blow his cover on the first night because his STUPID EYES GLOWED IN THE DARK.
--
“His eyes were glowing,” Bruce said. Because of course he did. No wonder Tommy called him a snitch--
But Tommy started making noise into his pillow, too.
Laughing. Trying to muffle it.
“Were you dreaming about the Talon?” he hissed, sounding delighted.
--
Ignore it. Let this blow over.
“What’s that?” He mumbled, still looking away.
--
Above Clark, Harvey Dent let out a groan under his breath.
Apparently, everyone was awake tonight.
If Tommy’s eyes could’ve glinted in the dark, they would’ve. “Oh, that’s right…. You’re from Kansas. You don’t know about… the assassins….”
“Oh my god,” Harvey Dent whispered only to himself.
--
… Clark finally lifted his head and glanced back at the other bunk.
“What.”
--
“It’s a fairy tale in the area,” Harvey said finally, whispering loud enough for the other two in the room to know he was also a little snitch. “Tommy likes to scare new kids with it. Now shut up, we’re gonna get in trouble.”
Tommy flopped back onto his bed, huffing. “It’s fun to watch them freak out. It’s not like anything bad actually happens by just talking about it.”
“You got a quote for that?” Bruce mumbled, half audible in his pillow.
“Ugh. ‘Happiness depends on ourselves?’ Or in this case, in letting me tell a ghost story in the middle of the night, you babies.”
--
“Fairytale assassins?” Clark couldn’t help but snort and roll back over so no one could see his eyes.
“Guess you city kids gotta have some kinda boogiemen.”
--
…..
Tommy sat up in bed, eyes narrowing.
“What’s that supposed to mean?”
--
“Well back home we got things like portals to hell and angry ghosts, not assassins.”
--
...somehow, that seemed to settle Tommy, a little.
“No room for that stuff here,” he said. “Just threatening nursery rhymes that date back definitely two hundred years and if you want it creepier, even longer.”
--
“... Assassins with nursery rhymes?”
Sounds pretty lame.
--
“Still spooks people enough,” Tommy said, shrugging. “Especially in this kinda place.”
“It’s nice to think some random murders might’ve had a point,” Bruce said.
Tommy did not respond to that.
--
“Dunno how anyone could get spooked in a place as loud as this.” Clark said, sighing.
No room to think enough to be scared.
--
….for a moment, the three regarded him in incomprehension.
“Oh,” Harvey said. “Oh, he’s not used to the city.”
There was a small sound of understanding from the other two.
“I was gonna say. It’s dead quiet, honestly,” said Tommy.
“Not if we get caught talking,” Bruce warned. “Shh.”
“Shhhhhh,” Tommy said.
--
Clark groaned his own ‘nnnngh’ and shoved the pillow over his head.
It didn’t help.
Somewhere out of normal hearing a car alarm went off.
“You gotta be kidding…” He whispered to himself.
--
At least, finally, the conversation, thin as it was, had died out.
(There wasn’t any explanation for why Tommy would think Bruce dreamed of Talons when it was just a silly boogey man.)
But the three boys settled down in their beds again.
Bruce started breathing deeper. More intentionally. Until it relaxed him enough to get back to sleep.
...his heartbeat deepened and steadied out. Much closer than the car alarm.
Tommy and Harvey’s followed.
[...]
He wrote to his parents.
Everything is going well. Making friends. They're all rich but not as full of themselves as I thought they would be. It's pretty cool. Really loud here though. Having a lot of trouble sleeping.
Love you.
Then it was just… back to normal. Like he hadn't found out the teachers beat their students.
--
(When his mother wrote back, she was so relieved he was making friends. That it wasn't as bad as she feared.
But he wouldn't get that letter for another two weeks.)
The next week rolled around, and Bruce grew a little quieter. Tommy didn't, but Harvey quietly told Clark to be extra careful this week. It was an anniversary, he said, assuming that by now Clark knew, Kansas or not. And sometimes Bruce got a little mean during the anniversary.
Not just standoffish, but.
A little aggressive? Sometimes.
...and so the 26th rolled over, and even though Tommy seemed to be pretending it was a normal day, the rest of their dorm room woke up with stale, held breath.
Bruce avoided people. Avoided radios and TVs playing the news.
But somehow, he didn't manage to avoid the newspaper, and did a double take when he saw the headlines.
Finally, something had overshadowed him a little.
On the front page was the picture of a grisly murder. Open-eyes, holes in his face--
“REAL ESTATE SUPERSTAR FOUND DEAD IN PENTHOUSE SUITE; DEATH OF A THOUSAND CUTS!”
--
Clark tried to keep it in mind. Unlike the other two he didn’t treat it like any other day because it wasn’t. They still all went through the motions of course, but he talked to Bruce a little softer. A little gentler. Not because he wanted to walk on eggshells, but because he knew for Bruce that this wasn’t just another normal day, and acting like it was felt like almost a slap in the face of what he had to go through.
Maybe it hadn’t occurred to him that Bruce would want to avoid the papers. It was hard for him to wrap around the fact one of his roommates was so rich that his parent’s death made it into the news every single year somehow, so maybe it was his fault that Bruce saw the headline. He read the paper almost every day if he could. He wanted to be a journalist, after all, and they didn’t have TV in their room. Sometimes the common room TV wasn’t even on.
But he saw the murder too and, at this point, didn’t think much of it. Read the article and moved on.
Gotham, he had learned very quickly, was just as bad as everyone said.
--
It made sense, why Gotham Academy reassured all their parents that they would keep the children safe.
And maybe that was Bruce’s fault, he thought. Because it wasn't as if he was expecting papers to talk all over again like the day it'd been, but--
He'd expected a talk piece. An opinion article.
One Year Later: Flowers Left At Wayne Memorial Event as Investigation Dies
Two Years Ago, As Martha and Thomas Wayne Laid to Rest, Crime Began to Rise
Three Years Since Gotham’s Kennedy’s Mown Down: Park Row Died with Them?
A Reflection on Gotham’s Economic Fall: Wayne Fortune Locked Up as Charities Run Dry
(Sole Survivor Wayne to Attend Gotham’s Most Prestigious Academy This Fall with Luther Heir)
Five Years Ago Today: How the Wayne Deaths Marked the End of a Safe and Glorious Gotham
He could imagine what the headline should've been. What it should've been.
Instead, Six Years of Sorrow: Wayne Murders Still Shadow Upper East Side and Wayne Murder Theater Announces Close on Anniversary of Deaths, citing ‘Unrecoverable Reputation’ of the Area had been pushed down the page to make room for the new murder.
...and Bruce took a look at it and snatched it up to stare at the grisly photo and start to read.
--
It was a good thing that Clark had a loose grip on it as it was yanked from his hands.
“O-kay. You coulda asked.” He said, but didn’t sound angry. Still being soft around Bruce due to the day it was.
He feared he might’ve done something wrong.
--
Bruce managed to give him a hum of some sort of acknowledgment, but didn't really give much of a response.
He went to his bag, grabbed a pen, and sat right down on the floor, tracing the bottom of the words in the paper to keep his place.
Tommy leaned out from his bunk to try and watch over Bruce's shoulder, but his eyes looked uninterested. “Saw somethin’ ya liked?”
(Bruce shot him a disgusted look, a “what?” but otherwise ignored him.)
--
Clark leaned over too in order to watch him. “Or somethin’ ya didn’t like.”
--
Bruce glanced up at him, too, but looked more self-conscious than anything at that.
“The way they're talking about the thing just reminds me of the claw marks they found at the Lansing murders…”
“Oh my god,” Tommy said in a familiar kind of disbelief for this specific topic. “It was a dog claw, Bruce.”
--
Clark, however, was interested.
“Lansing murders?”
--
Bruce shrank down under Tommy’s criticism, but… looked up again, and quietly answered Clark’s tone.
“...the Lansings were a business couple,” he said. “They were murdered in their home the summer before last by stabbing a, so not… like this.”
For a moment, he backed up again, and let Clark see the slashes of the man on the page.
“Something left a big claw mark on the door, and their dog--”
“Ran away from home and wasn't seen again,” Tommy said dully. “It obviously hit the front door. Broke the hinges. Ran off in fear. It was a hundred pound dog.”
“...” the look on Bruce’s face said he didn't believe it all the way.
But he didn't lift his head to argue this time. He just stared down at the paper.
“...Bruce, hey, I'm not trying to make fun of you, I'd never do that,” Tommy said, rolling a little closer to the edge of the bed. “But just because claw marks happened once or twice at a murder doesn't mean the Court is real. What, did your dad have a gash on his face when he died?”
And Bruce shook his head.
“See? It's not real.”
--
“Well that don't mean you can't look into it.” Clark offered, looking up at them. “What's the harm in connecting a few dots? And just because there ain't proof they do exist doesn't mean they don't.”
--
Tommy gave Clark the kind of flat look he never gave Bruce. Like he was saying the dumbest thing.
“You didn't even know the story when you showed up and now you're trying to do this? Really?”
...Bruce stared up at Clark, face unreadable.
And he started to pick up the newspaper and fold it again.
--
“Tryin’ to do what?” Clark frowned. “If there's a story here I'm interested! Y'know--” he gestured to himself, “journalism?”
--
“To drag him down again!” Tommy said, rolling off then bed and standing, defensive behind Bruce. Above him.
For the moment.
For the moment before Bruce stood, pencils and notebook in hand, and paper carefully folded under his arm.
He looked at Clark.
“Let's go.”
--
Clark glared at Tommy, but he said nothing.
He grabbed his own notebook and pencils to leave with Bruce.
--
“Bruce?” Tommy said, but Harvey was the only one still listening. “Bruce!”
Bruce closed the dorm door behind him.
“Library has old papers on record,” Bruce said softly. And he began to walk.
--
Whatever history was repeating here, Clark knew nothing of it.
“Okay,” he said, and started heading that way.
“... Tommy said I was ‘dragging you down again’. What’d he mean by that?”
He sounded annoyed. Offended. Like he would do that to someone intentionally.
--
Bruce pursed his lips, buying time for a response, but not sure what to say. Or, he knew what to say.
But he didn't like to say it.
“...I tried to find the man who killed my parents,” he said finally. “...I couldn't.”
--
“You think they’re all related to that Court?”
--
Bruce hung his head.
Stared at the ground.
Didn't… want to look Clark in the eye when he admitted his stupid, idiot theory.
“...they’re all building developers. Or owned lots of property. And were trying to change it…”
--
But Clark didn’t call it stupid.
“Okay, something to start with. And, hey--”
He reached out slowly to touch Bruce’s shoulder.
“Worst case scenario is we’re wrong and nothing changes.”
--
Bruce twitched a little at the contact, but…
Mostly, he just turned his head up a little, and stared at Clark’s face.
(He was sixteen and he'd stopped believing in a just world long ago.
But somehow, he was stupid, and still believed in fairy tales.)
“Okay,” he said, voice cracking.
And he led Clark to the library.
...the newspapers were all in the bottom floor, the basement. In the archives. The indexes were massive, but well organized and maintained.
And Bruce already knew where to start looking… to a point.
But the first place to start, was writing down a scrawled poem on a blank sheet of scrap paper. Hesitating.
“...we’re doing this backwards,” he mumbled. “Not supposed to go in with a theory…”
But he wrote it out, all the same.
Beware The Court of Owls, that watches all the time,
ruling Gotham from a shadow perch, behind granite and lime.
They watch you at your hearth, they watch you in your bed,
speak not a whispered word of them or they'll send The Talon for your head.
--
Clark followed him down.
“No?” He asked, setting his notebook on a desk close to the archives they would need to look through.
“How do you think we should go about it then?”
--
Bruce swallowed and stuffed the paper in his pocket.
“...supposed to go in and look for patterns and connections,” he said. “...if you already have a suspect, you… only look for things that point to them.”
--
“... Okay. How much can you tell me about this ‘Court of Owls’?”
He was sitting down and opening his notebook to a new page. He didn’t have the knowledge of them Bruce did. This wasn’t his home. These weren’t his urban legends.
--
Looking for them directly was exactly what Bruce said they shouldn't be doing, but…
It still thrummed inside him, on some silly, stupid level.
Maybe it hadn't just been a coincidence murder. Maybe it had a purpose. Anything other than random events. Anything.
“...” he handed Clark the paper. “...they have at least one assassin. They… Have an architecture motif. They're watching from the buildings.”
With the kind of architecture in Gotham Academy not being uncommon to the rest of Old Gotham, it maybe wasn't surprising the buildings themselves were the boogeymen’s hiding places sometimes.
But he didn't know if Clark would make that connection to a real estate building mongle--
--
“Ties in to your theory about them targeting building developers.” He said, writing something down before he got up so he could look into those Lansing murders Bruce had talked about earlier.
He needed to play catch-up. This wasn’t his turf. He didn’t know as much as Bruce did.
He planned to dig up the papers about the Wayne tragedy too, but… not now. Not with Bruce in the room.
Clark could do that later on his own time.
--
Tommy had seen the connection, and rolled his eyes, and Bruce half expected Clark to just-- not see it at all--
But he swallowed something down, and his stomach stopped roiling quite so much, and he nodded again.
“Yeah. Just. Anyone who changes the architecture.”
And he dove in behind Clark.
He looked for the more recent murders. The ones he hasn't read about or studied like this since he was twelve and finally gave up, run off from his last scraps of energy.
And finally, someone was beside him, willing, even for just a moment, to believe him.
--
While Bruce looked at the more recent murders, Clark went for the old. The ones Bruce already knew about. He asked him which ones he had connected before, if any, and he would take a look at those.
(“I’m a new perspective. I wanna go over things you already know about. We don’t think the same, so who knows. Maybe I’ll see something different.” Is what he would say.)
The Lansing murders. What they did before the murders. The other ones that Bruce had tied together when he was 12--
Before they knew it the library was closing. They would need to come back.
And they would.
--
(A new perspective. A new reading level, honestly-- from twelve to sixteen, the change in things he understood--)
They would come back.
Absolutely.
Bruce went to bed and slept the whole night, and woke with impatient fire in his eyes.
Tommy gave Clark a sour look as Clark headed out the door to change, and once again as Bruce flew out of his last class, tossing his bag into their dorm and making a beeline to the library.
“Bruce, but, homework--!” Tommy called.
“Don't bother,” Harvey sighed, sitting down with his own book bag to get started “It’s not like his grades will get him kicked out.”
….and on the weekend, Tommy barely had time to pull on a matching hoodie and jeans, before Bruce was out the door for early breakfast and back to work.
(“Nice to see him care about something,” Harvey said.
Tommy threw a pillow at his head.)
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black-streak · 4 years
Text
Waiting for the Worms - Empty Spaces
Part 2
Please heed warnings of part 1. Added warning of suicidal tendencies. If Anything about suicide makes you triggered, don't continue reading this particular story. Please be mindful of yourself. This WILL get worse.
Tag list of known masochists (I'm playing, you guys are amazing):
@northernbluetongue @thethirdwheelfriend @shizukiryuu @theatreandcomicfreak @michellemagic @karategirl119 @moonlightstar64 @my-name-is-michell @mystery-5-5 @zalladane @queen-of-the-trash-planet-tm @wuvpancakes @dorkus-minimus @jardimazul @allthebooksandcrannies @g-arya @worlds-tiniest-spook-pastry @persephonescat @mycupisbroken @luciferge @18-fandoms-unite-08 @dawnwave16 @alwaysreblogneverpost @kris-pines04 @mysteriouslyswimmingfan-blo-blog @weird-pale-blonde-person @you-will-never-know-how-i-think @kokotaru @naclychilli @slytherinhquinn @clumsy-owl-4178 @ladybug-182 @darkthunder1589 @evil-elf16 @lysslovsanime
~---~
Coming to in Marinette's body was jarring to say the least. Moments earlier, pain was all he could register and now he was leaning back on a bench in the back of a classroom. 
Leaning forward and hiding his face in his arms, he focused in on the tug in the back of his mind, trying to bring it forward. To force the switch back, only to be met with harsh resistance.
"Dammit Mari, don't do this. Let me back!" He whispered under his breath, panic starting to lurch to the forefront. He started to shake all over, the longer the connection lasted and the longer she resisted.
"Marinette, please stop, please? You can't keep doing this," he murmured, slowly rocking back and forth, pushing with all he had at the bond.
"God, how pathetic can she get? Faking a breakdown for attention," a voice from the front spoke, pitched just right to be intentionally heard by him.
"Why don't you mind your own damn business," a haughty voice exclaimed from his left, before a body drew closer, arm wrapping around his shoulder. He held back a flinch, trying to tune into her normal reliance on others for comfort, instead leaning into the body, vaguely recognizing it as Chloe. 
The resistance dropped and finally the tug calmed down. He still couldn't switch back, but she wasn't fighting him anymore either. He let out a sigh as the shaking calmed down. Bruce must've found her. She was safe, but likely exhausted and unable to switch back. As much as he hated her taking the pain for him, all he could do now was wait for the bond to pull again and leave a letter detailing exactly what he thought of her little stunt here.
This time Jason did flinch. He felt the first few blows Joker landed, he could only imagine how much pain she must be in now.
"You okay there, marzipan?"
That was a new one. Glancing up into worried baby blues, he gave one soft nod and slumped into her side, paying attention to the lesson. Mari would be upset if he let her fall behind in her studies while she was gone.
It had been four days since then and Jason couldn't help feeling like something was horribly wrong. It wasn't the first time they switched for an extended period of time, by any means, but his gut told him this time was different.
Sure she had claimed his body for well over four days before to wait out an injury or get more extensive training with Bruce before and he had held her body hostage for over a week once when she was in the hospital with pneumonia, but normally a tug or two would tell him that one of them was holding out on the swap.
This time, nothing came. His mind was achingly devoid of her and as the days passed, he feared he might end up here longer than planned. It would make sense. Multiple broken bones, blunt force trauma, and the sheer force of their swap could easily have overwhelmed his body and dropped it into a state of unconsciousness. 
He took to her computer, trying any combination of words related to the accident to see if anything had been reported only to come up empty handed.
That couldn't be right, if she were in the hospital, if his body was properly reported as a Joker victim, the report would be made public, even if the identity was kept under wraps for being an unknown minor. Anything to indicate someone was caught up in the accident. Surely Bruce wasn't relying solely on Alfred to patch them back up?
It wasn't until a week after the incident that he received his answer, buried in a tiny little notice in the back of a Tuesday local newspaper. Like an afterthought. Amongst the obituaries. A tiny note that the late Jason Peter Todd had died.
His soulmate died in his body and didn't even make it into the citywide Sunday paper. Just a local midweeker with barely more than two sentences.
Disbelief struck first.
This couldn't be real, right? Soulmates weren't able to just. Die in the other's place. That wasn't a thing. It was his body, if anything, he would have immediately been evicted the second his body died and moved on while she returned to hers. So how the fuck was he still here?
Next came anger.
How dare Marinette die in his place. How dare she end her life for his mistakes! And by the Joker! The fucking Joker deserved to die for torturing and killing his sweet little soulmate. He deserved a life worse than death. To be strung up and peeled apart inch by inch until he begged for death. And Batman... How dare he not make it in time to save her. It'd be okay if it were him, but not her! She didn't deserve this. Mari had her own life, her own desires and dreams, her own villain to hunt down, and that was torn away from her because Batman let them down. But even worse, Bruce barely cared enough to be open about his death. To mourn the loss of her like he did, even if the man didn't know it was an innocent in that body and not him. And even if it had been, it hurt knowing that he alone wasn't worth more than a barely there acknowledgment that he was once alive in an unseen back page.
Last came devastating grief.
She was gone. Marinette, the girl who never even really met him, cared so much for him, she sacrificed her own life for his. Forced him to stay in her body and took his as her own to the grave so he could live as her. With her loving parents and colorful room and warm heart. She gave him everything and wanted nothing in return. Slept on the streets for him at times, took brutal fights on as Robin so he could have a reprieve, skipped meals so he could taste something he'd never had before that her parents made that night. Learned English from an early age so they could talk and he wouldn't be alone in the world. And now that one of them had died, she ensured that he would be left in the best environment she could provide him, even if it had become rougher around the edges from when they were younger. And now she was gone. Dead. Never to return. And as he turned towards the mirror and looked into her beautiful, glowing blue eyes, he saw the tears trail down her face before he collapsed into himself, cursing anything and everything in the universe for allowing such a cruel fate.
For the next month, he moved through life like a zombie. As much as he hated her classmates for treating her the way they had, he couldn't help but feel grateful that no one wanted anything to do with him. They still muttered under their breath and glared and purposefully manipulated situations against him, but no one tried to ask what was wrong.
Everyone but Chloe and Juleka avoided him like the plague, which felt accurate in a sense. He didn't have to fake a smile or pretend to be okay like he had when the class still loved her. He could sulk and cry and grieve and it went unquestioned. The others hated him and the two girls, while worried, knew that sometimes she needed the reprieve of just letting her negativity go unchecked for a little while to make up for bottling so much of it all the time, so they let it go as well. The teacher barely glanced his direction. If it weren't so beneficial to him at the moment, Jason would be pissed at the obvious neglect his soulmate had endured at the hands of this lot. As it stood, he just cried a little harder at night in his grief, Tikki curled to his neck with tears of her own. 
The two quickly bonded over their mutual loss and the inability to talk about it to anyone else. Despite the stress of it, Jason refused to let anyone else know that Marinette had died. Her parents didn't need to suffer her death while looking at her living, breathing body, knowing she wasn't in it. That it was his fault she had died in the first place. And he couldn't even imagine having to tell them how she died.
So he resolved himself to live in her stead. To live as she would for the sake of her loved ones and in her honor. He had enough practice in the past to pull it off. It helped that they had both learned to suppress their emotions to the point of nonexistent in the light of facing Hawkmoth.
That was another thing entirely, though. While he resolved to fake a smile and play the happy designer in her civilian life, Ladybug took a turn from that day forward. He warned the cat off him, not playing into the teasing and banter, becoming stoic and professional. And when the kid got too brash, too pushy, too unreliable, he stripped the ring from him and moved on. Built a team she would've been proud to lead.
Over the next three months, he slowly adjusted her mannerisms to be more natural for him. Not enough to be noticeable or seen as anything more than growing older and slightly more jaded, but enough to make it a touch easier and less like he was living a lie.
Six months had passed and everything was different. 
The rest of the class didn't bother him. Didn't make accusations. Throw insults. Acknowledge his existence in any way. And maybe that was meant to be punishment. To be treated as a ghost haunting an unknowing audience. But it was pure bliss. He couldn't thank them enough for their continued silence. 
At least this way he could pretend her last days of life were happy and surrounded by people who cared for her. That they were grieving her just as he was.
There were still mornings he forgot. Times he'd walk by a mirror and smile, seeing her looking back and thinking it just another of their sporadic swaps where he'd wake as her and find a note waiting for him. 
Then reality would crash around him as the little kwami would come out and look at him with those sad eyes, nuzzling his neck (her neck, this was her body god dammit). On those days it hit him differently. Sometimes he'd shut it all down, going through the motions for the rest of the day. Other times he'd break down and cuddle the small being as close as possible and share in her despair, not bothering to leave the house. Usually anger would coarse sharp and deadly through his heart, urging him to seek vengeance. On those days, any remarks made his way were brutally rebutaled, until the remarks stopped entirely. Ladybug fought with just a little more violent intent; he couldn't avenge her until Hawkmoth was defeated. Those gorgeous blue eyes set into her face turned into a deadly storm of promised danger. 
It all kept swirling and cycling through him over and over until one day, the desperation and grief and hurt all hit a little too hard and he laid on the floor, staring up at the dark ceiling, wishing he could be by her side. That he could join her and not have to feel like this anymore. That it could all just go away and he could be happy for once in his miserable life.
That night he wished for nothing more than to die. If it hadn't been for the absolute heartwrenching sight of her little, pale hand wrapped around a too big knife, he has no doubt he would have gone through with it. 
Afterwards he could only thank his cowardice for preventing him from destroying her body like that. She wanted him to live and who was he to deny her? 
That night, he curled up on the cold, hardwood floor and begged her forgiveness, promising to do better. To be better. He knew she couldn't hear him, would never respond, but he begged all the same.
565 notes · View notes
Text
muse rundown.
bael: hellhound, owned by felicity. “top dog” of her hellhound army. a very bad boy to anyone that isnt felicity. likes to chew on stuff. won’t accept anything else, he wants whatever you have & that’s it. just because he’s sometimes goofy doesn’t mean he won’t eat you whole real quick.
beck: werewolf. a good girl. goth / grunge aesthetic. avid coin & crystal collector. taxidermist. can pole dance.  super short but will still kick your sorry ass. dont call her the mom friend. easily stressed out.
dylan:  ((( very ))) low ranking angel. flies under the radar a lot, so he gets away with a lot of shit he’s not supposed to do. really likes flamingos & the color pink. lowkey kind of a fuckboy but doesn’t mean to be. meme lord 9000. just wants to have a good time & make people laugh. has the voice of an angle ( lmao ). he’s lovin life.
felicity: high ranking demon. really loves hellhounds so she adopts literally all of them. she’s small & cute but don’t let that fool you. she a bad bitch. kind of a trouble maker but only when the mood strikes. really like chocolate.
heaven: human.  lives in a tiny apartment with a grumpy old cat shelter cat named norman. manga / comic artist & cafe barista.  college dropout.  trying to live that main character life to see if anything actually interesting happens
hercules: doll, affiliated with 1 of my main blogs / tala.  strongest doll to be made yet. bodyguard for hire. people call him daddy but he is actually grandpa. let him eat his applesauce and rest. too tired to deal. looks bangin in leather.
hixdus:  alien / god. part of a series i once had where the universe(s) are maintained & created by 6 individual gods. hixdus is the star maker aka father of stars.  kind of an asshole & a sucker for romantic stuff yet doesn’t have much interest in dating. just wants to pay rent.  he’s a good guy, promise.
monroe: witch of poison. immune to toxins, both natural & manmade. has a garden of dangerous plants & an assortment of dangerous animals, mainly venomous snakes & frogs.  does medical research to help develop antidotes to toxins / use poisons to develop medicines. scary looking dude but honestly doesn’t have a mean bone in his body.
lafayette: doll. he was made for medical practice, specifically to test out medications without the risk of harming people. has online friends, kind of an anxious guy but suppresses the fuck out of it.. judgmental as fuck.
michelangelo: human. nicknamed ‘angel”. has his own co-ed stripclub called “heaven’s gates” and the strippers are called angels as well. he’s a really fun dude. just wants to have a fun time. really fucking relaxed, but runs a tight ship when it comes to the club. don’t touch his dancers.
orion:  phoenix. literal sunshine. runs a bakery  / coffee shop with his younger sister, angelina. he’s not very good at baking or decorating but he tries his best. he’s mainly handling customers. don’t let him have coffee. wants to be friends with everyone.
rafiane: alien / god. hixdus’ brother. makes planets / strings together solar systems. high energy. kind of an idiot but still pretty damn smart. kind of new to the whole earth thing, but hixdus has pretty much got him settled in real quick. really loves sour things. can eat a whole lemon. sweet dude but easily confused.
rosalie:  vampire. bubbly as fuck. generally a nice girl, but can get violent at the drop of a hat. she doesn’t like hurting people, but she isn’t against it. very much into lolita / cutesy fashion. she’ll let you borrow her clothes. her hair literally drags on the floor. she’s a vampire Rapunzel.  has royal english blood, but that was a long time ago, so she got that old money keeping her filthy fucking rich.
toka: fear eater: mechanic / street racer. makes money mainly off of motorcylces & sports cars; both repairing & illegal racing — he’s pretty damn good at winning bets & gambling. really fucking creepy & not an approachable guy. he’s already scary looking, but he’ll try to look even scarier to avoid conversation. hates his neighbors. he’s not a bad guy —- he doesn’t intentionally want to physically hurt anyone, just spook them for a good meal. usually he feeds in the form of manipulating dreams to nightmares, since he won’t scare people half to death, but it produces less energy for him to soak up. he’s pretty indifferent about causing people emotional & mental scarring when it comes to scaring people; still would rather do it painlessly through dreams though. boy’s gotta eat.  chaotic neutral. 
valentine: human. owner of the grand rosette hotel.  magic is rooted in both his blood & the hotel. it’s basically like a whole new world, or several worlds. he can kind of play god, being the blood owner of the hotel. the elevators will fuck you up for 5 minutes every 2 hours, meaning that when the clock strikes, the elevators will actually take you to different worlds inside the hotel where several people live. valentine can control these worlds.  really likes wine. kind of a neat freak. wears a lot of fur; both fake and faux. has a few cats that live in the hotel & just wonder. friendly guy. kind of a huge flirt. very proud of his family.
4 notes · View notes
lauramalchowblog · 5 years
Text
A National Patient Identifier: Should You Care?
By ADRIAN GROPPER, MD
The rather esoteric issue of a national patient identifier has come to light as a difference between two major heath care bills making their way through the House and the Senate.
The bills are linked to outrage over surprise medical bills but they have major implications over how the underlying health care costs will be controlled through competitive insurance and regulatory price-setting schemes. This Brookings comment to the Senate HELP Committee bill summarizes some of the issues.
Who Cares?
Those in favor of a national patient identifier are mostly hospitals and data brokers, along with their suppliers. More support is discussed here. The opposition is mostly on the basis of privacyand libertarian perspective. A more general opposition discussion of the Senate bill is here.
Although obscure, national patient identifier standards can help clarify the role of government in the debate over how to reduce the unusual health care costs and disparities in the U.S. system. What follows is a brief analysis of the complexities of patient identifiers and their role relative to health records and health policy.
Patient Matching
Patient matching enables surveillance of patient activity across service providers and time. It can be done either coercively or voluntarily. We’re familiar with voluntary matching like using a driver’s license number to get a controlled substance prescription. People are not aware of the coercive matching that goes on without our consent.
Voluntary matching is cheap and reliable. Coercive surveillance for patient matching is quite expensive and prone to errors. Why would so many businesses promote the coercive alternative? It’s mostly about money. The relationship between health surveillance and money in the U.S. healthcare system is relatively unique in the world. The issue of a national patient identifier is also pretty specific to the U.S. The reasons, as all things in U.S. healthcare, are complicated. But, fundamentally, they boil down to two things:
Patients have a right to be treated without identification — what HIPAA calls “known to the practice” — but paying for that treatment clearly requires some identification.
The byzantine financial incentives in the U.S. system mean that thousands of data brokers have a financial interest in the hidden surveillance. Otherwise, they would just ask patients for consent.
Insurance
Payers already have a patient identifier. The impact of adding a surveillance component, either voluntary or coercive, is hard to estimate. Would patients have a choice of plans with or without coercive surveillance? Would we need regulations, similar to GINA, to reduce the risk of biased interpretation? I’m not aware of any insurance industry comments on the House national patient identifier amendment.
All Payer Claims Databases
Pretty much everyone in the health care “system” is working as hard as they can to avoid transparency. Transparency of quality, of cost, of data uses, of directories, of “black box” and artificial intelligence algorithms, and more. The principal strategy for both the House and Senate versions of the cost reduction bills is to increase transparency, but that could be achieved with either coercive or voluntary identifiers.
Prescriptions
Coercive patient surveillance is already in place on a massive scale. Surescripts tracks over 200 million U.S. patients and sells that information for all sorts of purposes without patient consent or obvious oversight. In theory, one can opt-out of Surescripts. In practice, it’s practically impossible. (I tried it.) I did find errors in my file. Even fixing those errors was more trouble than it was worth. Would Surescripts’ coercive surveillance be mitigated by a national patient identifier? Quite possibly, if the final legislation introduces privacy protections, such as opt-in and real-time patient notification by Surescripts or anyone else that is making use of the identifier.
Known to the Practice
HIPAA encourages a trusting physician-patient relationship by allowing confidential and even anonymous consultation. This promotes public health. The implementation of a national patient identifier must preserve this option.
TEFCA
The federal government has been trying to create a national network for health records for over a decade. The current state is the Trusted Exchange Framework and Common Agreement (TEFCA) Draft 2. TEFCA is still far from obvious with major detractors from the incumbents and no clear solution to the very hard problems of regulatory capture of standards, security, consent, and patient matching. Three comments by Patient Privacy Rights address these issues.
Aside from moving patient data from here to there, TEFCA aims to provide a surveillance mechanism that will track the locations where patients receive health services. This can be quite useful for maintaining a longitudinal patient record, measuring outcomes, and informing research, as well as policy.
But a national surveillance system can also spook patients and increase public health risks if populations concerned about bias and loss of opportunity hide or actively game the system. It’s therefore essential to design TEFCA with the highest level of privacy and transparency, similar to what we have in finance. A national patient identifier will help TEFCA, but only if it is voluntary (linked to consent), transparent (to mitigate security risks), and most importantly, if it replaces the current design based on coercive surveillance.
Privacy
People already have any number of national-scale identifiers. Mobile phone numbers and the unique device identifiers that phones broadcast just by being on, email addresses, driver’s license numbers, Medicare and private insurance IDs, a Social Security Number, and credit cards. What matters for privacy is not the existence of personal identifiers but how they are used. Is the usage regulated? Does use in one domain, e.g. purchasing, cross over into another domain such as taxation? Is the use of the identifier voluntary like when you sign to allow your credit surveillance history to be accessed by an auto dealer or a landlord? Are you notified whenever an identifier is used? Are there usage logs and statements conveniently available to you? A national patient identifier will need to answer all of these questions and more.
Errors, bias, and ethics
Every large system is subject to errors, bias, and ethical issues. The proponents of a national patient identifier make self-serving arguments about reducing errors, such as assigning data to the wrong patient, without a critical analysis of how errors might be intentionally or accidentally introduced into the system. Other questions include how patients can catch errors or omissions and how access to a national identifier might bias relationships with employers or a new generation dating sites. The ethics of health care are mostly about the unintended consequences of what superficially seems like a good idea.
Coerced, Voluntary, or Self-sovereign
Self-Sovereign Identity (SSI) that is cryptographically secure and controlled by the individual person. If we introduce a national identifier, for patients or any other large-scale use, in 2020, should that identifier be compatible with SSI?
Independent Patient-Controlled Longitudinal Health Record
A new national patient identifier is not an end in itself, it must serve or enable something new. That new thing could be universal healthcare coverage, which exists in almost every other developed economy. Another new thing would be a longitudinal health record that is independent of any particular public or private institution. An independent health record would promote competition, enable greater transparency of outcomes and costs, and it would significantly reduce the costs of research and innovation. It’s important to design TEFCA and other federal programs around the outcome rather than a tweak of the process.
Non-HIPAA Components
What would be the scope of a new national patient identifier? Should it be used to add non-HIPAA components like exercise or diet to a patient’s record? Should it apply to over-the-counter purchases in pharmacies or telemedicine from outside the US? Will the new identifier expand the scope of surveillance by Facebook, Google, and other hard-to-avoid platforms?
Should you care?
Yes. The uniquely high U.S. health care costs are now driving politics directly and indirectly. Universal coverage could be the top issue in 2020. But health costs also impact immigration discussions, as well how we deal with technology-driven shifts in employment and employer-based insurance.
Bi-partisan efforts such as the “surprise medical bills” legislation now before the House and Senate are aimed at health care cost outcomes and the balance of power between hospitals, payers, patients, physicians, and regulators. That balance of power was swept under the political rug in previous efforts. With health care waste and fraud running at about $1.5 trillion or 6 percent of GDP, the debate over a national patient identifier should not be about the process of patient matching but over the path to increased transparency, competition and innovation.
Adrian Gropper, MD, is the CTO of Patient Privacy Rights, a national organization representing 10.3 million patients and among the foremost open data advocates in the country. This post originally appeared on Bill of Health here.
A National Patient Identifier: Should You Care? published first on https://venabeahan.tumblr.com
0 notes
kristinsimmons · 5 years
Text
A National Patient Identifier: Should You Care?
By ADRIAN GROPPER, MD
The rather esoteric issue of a national patient identifier has come to light as a difference between two major heath care bills making their way through the House and the Senate.
The bills are linked to outrage over surprise medical bills but they have major implications over how the underlying health care costs will be controlled through competitive insurance and regulatory price-setting schemes. This Brookings comment to the Senate HELP Committee bill summarizes some of the issues.
Who Cares?
Those in favor of a national patient identifier are mostly hospitals and data brokers, along with their suppliers. More support is discussed here. The opposition is mostly on the basis of privacyand libertarian perspective. A more general opposition discussion of the Senate bill is here.
Although obscure, national patient identifier standards can help clarify the role of government in the debate over how to reduce the unusual health care costs and disparities in the U.S. system. What follows is a brief analysis of the complexities of patient identifiers and their role relative to health records and health policy.
Patient Matching
Patient matching enables surveillance of patient activity across service providers and time. It can be done either coercively or voluntarily. We’re familiar with voluntary matching like using a driver’s license number to get a controlled substance prescription. People are not aware of the coercive matching that goes on without our consent.
Voluntary matching is cheap and reliable. Coercive surveillance for patient matching is quite expensive and prone to errors. Why would so many businesses promote the coercive alternative? It’s mostly about money. The relationship between health surveillance and money in the U.S. healthcare system is relatively unique in the world. The issue of a national patient identifier is also pretty specific to the U.S. The reasons, as all things in U.S. healthcare, are complicated. But, fundamentally, they boil down to two things:
Patients have a right to be treated without identification — what HIPAA calls “known to the practice” — but paying for that treatment clearly requires some identification.
The byzantine financial incentives in the U.S. system mean that thousands of data brokers have a financial interest in the hidden surveillance. Otherwise, they would just ask patients for consent.
Insurance
Payers already have a patient identifier. The impact of adding a surveillance component, either voluntary or coercive, is hard to estimate. Would patients have a choice of plans with or without coercive surveillance? Would we need regulations, similar to GINA, to reduce the risk of biased interpretation? I’m not aware of any insurance industry comments on the House national patient identifier amendment.
All Payer Claims Databases
Pretty much everyone in the health care “system” is working as hard as they can to avoid transparency. Transparency of quality, of cost, of data uses, of directories, of “black box” and artificial intelligence algorithms, and more. The principal strategy for both the House and Senate versions of the cost reduction bills is to increase transparency, but that could be achieved with either coercive or voluntary identifiers.
Prescriptions
Coercive patient surveillance is already in place on a massive scale. Surescripts tracks over 200 million U.S. patients and sells that information for all sorts of purposes without patient consent or obvious oversight. In theory, one can opt-out of Surescripts. In practice, it’s practically impossible. (I tried it.) I did find errors in my file. Even fixing those errors was more trouble than it was worth. Would Surescripts’ coercive surveillance be mitigated by a national patient identifier? Quite possibly, if the final legislation introduces privacy protections, such as opt-in and real-time patient notification by Surescripts or anyone else that is making use of the identifier.
Known to the Practice
HIPAA encourages a trusting physician-patient relationship by allowing confidential and even anonymous consultation. This promotes public health. The implementation of a national patient identifier must preserve this option.
TEFCA
The federal government has been trying to create a national network for health records for over a decade. The current state is the Trusted Exchange Framework and Common Agreement (TEFCA) Draft 2. TEFCA is still far from obvious with major detractors from the incumbents and no clear solution to the very hard problems of regulatory capture of standards, security, consent, and patient matching. Three comments by Patient Privacy Rights address these issues.
Aside from moving patient data from here to there, TEFCA aims to provide a surveillance mechanism that will track the locations where patients receive health services. This can be quite useful for maintaining a longitudinal patient record, measuring outcomes, and informing research, as well as policy.
But a national surveillance system can also spook patients and increase public health risks if populations concerned about bias and loss of opportunity hide or actively game the system. It’s therefore essential to design TEFCA with the highest level of privacy and transparency, similar to what we have in finance. A national patient identifier will help TEFCA, but only if it is voluntary (linked to consent), transparent (to mitigate security risks), and most importantly, if it replaces the current design based on coercive surveillance.
Privacy
People already have any number of national-scale identifiers. Mobile phone numbers and the unique device identifiers that phones broadcast just by being on, email addresses, driver’s license numbers, Medicare and private insurance IDs, a Social Security Number, and credit cards. What matters for privacy is not the existence of personal identifiers but how they are used. Is the usage regulated? Does use in one domain, e.g. purchasing, cross over into another domain such as taxation? Is the use of the identifier voluntary like when you sign to allow your credit surveillance history to be accessed by an auto dealer or a landlord? Are you notified whenever an identifier is used? Are there usage logs and statements conveniently available to you? A national patient identifier will need to answer all of these questions and more.
Errors, bias, and ethics
Every large system is subject to errors, bias, and ethical issues. The proponents of a national patient identifier make self-serving arguments about reducing errors, such as assigning data to the wrong patient, without a critical analysis of how errors might be intentionally or accidentally introduced into the system. Other questions include how patients can catch errors or omissions and how access to a national identifier might bias relationships with employers or a new generation dating sites. The ethics of health care are mostly about the unintended consequences of what superficially seems like a good idea.
Coerced, Voluntary, or Self-sovereign
Self-Sovereign Identity (SSI) that is cryptographically secure and controlled by the individual person. If we introduce a national identifier, for patients or any other large-scale use, in 2020, should that identifier be compatible with SSI?
Independent Patient-Controlled Longitudinal Health Record
A new national patient identifier is not an end in itself, it must serve or enable something new. That new thing could be universal healthcare coverage, which exists in almost every other developed economy. Another new thing would be a longitudinal health record that is independent of any particular public or private institution. An independent health record would promote competition, enable greater transparency of outcomes and costs, and it would significantly reduce the costs of research and innovation. It’s important to design TEFCA and other federal programs around the outcome rather than a tweak of the process.
Non-HIPAA Components
What would be the scope of a new national patient identifier? Should it be used to add non-HIPAA components like exercise or diet to a patient’s record? Should it apply to over-the-counter purchases in pharmacies or telemedicine from outside the US? Will the new identifier expand the scope of surveillance by Facebook, Google, and other hard-to-avoid platforms?
Should you care?
Yes. The uniquely high U.S. health care costs are now driving politics directly and indirectly. Universal coverage could be the top issue in 2020. But health costs also impact immigration discussions, as well how we deal with technology-driven shifts in employment and employer-based insurance.
Bi-partisan efforts such as the “surprise medical bills” legislation now before the House and Senate are aimed at health care cost outcomes and the balance of power between hospitals, payers, patients, physicians, and regulators. That balance of power was swept under the political rug in previous efforts. With health care waste and fraud running at about $1.5 trillion or 6 percent of GDP, the debate over a national patient identifier should not be about the process of patient matching but over the path to increased transparency, competition and innovation.
Adrian Gropper, MD, is the CTO of Patient Privacy Rights, a national organization representing 10.3 million patients and among the foremost open data advocates in the country. This post originally appeared on Bill of Health here.
A National Patient Identifier: Should You Care? published first on https://wittooth.tumblr.com/
0 notes
kristinsimmons · 5 years
Text
A National Patient Identifier: Should You Care?
By ADRIAN GROPPER, MD
The rather esoteric issue of a national patient identifier has come to light as a difference between two major heath care bills making their way through the House and the Senate.
The bills are linked to outrage over surprise medical bills but they have major implications over how the underlying health care costs will be controlled through competitive insurance and regulatory price-setting schemes. This Brookings comment to the Senate HELP Committee bill summarizes some of the issues.
Who Cares?
Those in favor of a national patient identifier are mostly hospitals and data brokers, along with their suppliers. More support is discussed here. The opposition is mostly on the basis of privacyand libertarian perspective. A more general opposition discussion of the Senate bill is here.
Although obscure, national patient identifier standards can help clarify the role of government in the debate over how to reduce the unusual health care costs and disparities in the U.S. system. What follows is a brief analysis of the complexities of patient identifiers and their role relative to health records and health policy.
Patient Matching
Patient matching enables surveillance of patient activity across service providers and time. It can be done either coercively or voluntarily. We’re familiar with voluntary matching like using a driver’s license number to get a controlled substance prescription. People are not aware of the coercive matching that goes on without our consent.
Voluntary matching is cheap and reliable. Coercive surveillance for patient matching is quite expensive and prone to errors. Why would so many businesses promote the coercive alternative? It’s mostly about money. The relationship between health surveillance and money in the U.S. healthcare system is relatively unique in the world. The issue of a national patient identifier is also pretty specific to the U.S. The reasons, as all things in U.S. healthcare, are complicated. But, fundamentally, they boil down to two things:
Patients have a right to be treated without identification — what HIPAA calls “known to the practice” — but paying for that treatment clearly requires some identification.
The byzantine financial incentives in the U.S. system mean that thousands of data brokers have a financial interest in the hidden surveillance. Otherwise, they would just ask patients for consent.
Insurance
Payers already have a patient identifier. The impact of adding a surveillance component, either voluntary or coercive, is hard to estimate. Would patients have a choice of plans with or without coercive surveillance? Would we need regulations, similar to GINA, to reduce the risk of biased interpretation? I’m not aware of any insurance industry comments on the House national patient identifier amendment.
All Payer Claims Databases
Pretty much everyone in the health care “system” is working as hard as they can to avoid transparency. Transparency of quality, of cost, of data uses, of directories, of “black box” and artificial intelligence algorithms, and more. The principal strategy for both the House and Senate versions of the cost reduction bills is to increase transparency, but that could be achieved with either coercive or voluntary identifiers.
Prescriptions
Coercive patient surveillance is already in place on a massive scale. Surescripts tracks over 200 million U.S. patients and sells that information for all sorts of purposes without patient consent or obvious oversight. In theory, one can opt-out of Surescripts. In practice, it’s practically impossible. (I tried it.) I did find errors in my file. Even fixing those errors was more trouble than it was worth. Would Surescripts’ coercive surveillance be mitigated by a national patient identifier? Quite possibly, if the final legislation introduces privacy protections, such as opt-in and real-time patient notification by Surescripts or anyone else that is making use of the identifier.
Known to the Practice
HIPAA encourages a trusting physician-patient relationship by allowing confidential and even anonymous consultation. This promotes public health. The implementation of a national patient identifier must preserve this option.
TEFCA
The federal government has been trying to create a national network for health records for over a decade. The current state is the Trusted Exchange Framework and Common Agreement (TEFCA) Draft 2. TEFCA is still far from obvious with major detractors from the incumbents and no clear solution to the very hard problems of regulatory capture of standards, security, consent, and patient matching. Three comments by Patient Privacy Rights address these issues.
Aside from moving patient data from here to there, TEFCA aims to provide a surveillance mechanism that will track the locations where patients receive health services. This can be quite useful for maintaining a longitudinal patient record, measuring outcomes, and informing research, as well as policy.
But a national surveillance system can also spook patients and increase public health risks if populations concerned about bias and loss of opportunity hide or actively game the system. It’s therefore essential to design TEFCA with the highest level of privacy and transparency, similar to what we have in finance. A national patient identifier will help TEFCA, but only if it is voluntary (linked to consent), transparent (to mitigate security risks), and most importantly, if it replaces the current design based on coercive surveillance.
Privacy
People already have any number of national-scale identifiers. Mobile phone numbers and the unique device identifiers that phones broadcast just by being on, email addresses, driver’s license numbers, Medicare and private insurance IDs, a Social Security Number, and credit cards. What matters for privacy is not the existence of personal identifiers but how they are used. Is the usage regulated? Does use in one domain, e.g. purchasing, cross over into another domain such as taxation? Is the use of the identifier voluntary like when you sign to allow your credit surveillance history to be accessed by an auto dealer or a landlord? Are you notified whenever an identifier is used? Are there usage logs and statements conveniently available to you? A national patient identifier will need to answer all of these questions and more.
Errors, bias, and ethics
Every large system is subject to errors, bias, and ethical issues. The proponents of a national patient identifier make self-serving arguments about reducing errors, such as assigning data to the wrong patient, without a critical analysis of how errors might be intentionally or accidentally introduced into the system. Other questions include how patients can catch errors or omissions and how access to a national identifier might bias relationships with employers or a new generation dating sites. The ethics of health care are mostly about the unintended consequences of what superficially seems like a good idea.
Coerced, Voluntary, or Self-sovereign
Self-Sovereign Identity (SSI) that is cryptographically secure and controlled by the individual person. If we introduce a national identifier, for patients or any other large-scale use, in 2020, should that identifier be compatible with SSI?
Independent Patient-Controlled Longitudinal Health Record
A new national patient identifier is not an end in itself, it must serve or enable something new. That new thing could be universal healthcare coverage, which exists in almost every other developed economy. Another new thing would be a longitudinal health record that is independent of any particular public or private institution. An independent health record would promote competition, enable greater transparency of outcomes and costs, and it would significantly reduce the costs of research and innovation. It’s important to design TEFCA and other federal programs around the outcome rather than a tweak of the process.
Non-HIPAA Components
What would be the scope of a new national patient identifier? Should it be used to add non-HIPAA components like exercise or diet to a patient’s record? Should it apply to over-the-counter purchases in pharmacies or telemedicine from outside the US? Will the new identifier expand the scope of surveillance by Facebook, Google, and other hard-to-avoid platforms?
Should you care?
Yes. The uniquely high U.S. health care costs are now driving politics directly and indirectly. Universal coverage could be the top issue in 2020. But health costs also impact immigration discussions, as well how we deal with technology-driven shifts in employment and employer-based insurance.
Bi-partisan efforts such as the “surprise medical bills” legislation now before the House and Senate are aimed at health care cost outcomes and the balance of power between hospitals, payers, patients, physicians, and regulators. That balance of power was swept under the political rug in previous efforts. With health care waste and fraud running at about $1.5 trillion or 6 percent of GDP, the debate over a national patient identifier should not be about the process of patient matching but over the path to increased transparency, competition and innovation.
Adrian Gropper, MD, is the CTO of Patient Privacy Rights, a national organization representing 10.3 million patients and among the foremost open data advocates in the country. This post originally appeared on Bill of Health here.
A National Patient Identifier: Should You Care? published first on https://wittooth.tumblr.com/
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