Medicare Is Faulted in Electronic Medical Records Conversion

The conversion to electronic medical records — a critical piece of the Obama administration’s plan for health care reform — is “vulnerable” to fraud and abuse because of the failure of Medicare officials to develop appropriate safeguards, according to a sharply critical report to be issued Thursday by federal investigators.

Mike Spencer/Wilmington Star-News, via Associated Press

Celeste Stephens, a nurse, leads a session on electronic records at New Hanover Regional Medical Center in Wilmington, N.C.

Centers for Medicare and Medicaid Services

Marilyn Tavenner, acting administrator for Medicare.

The use of electronic medical records has been central to the aim of overhauling health care in America. Advocates contend that electronic records systems will improve patient care and lower costs through better coordination of medical services, and the Obama administration is spending billions of dollars to encourage doctors and hospitals to switch to electronic records to track patient care.

But the report says Medicare, which is charged with managing the incentive program that encourages the adoption of electronic records, has failed to put in place adequate safeguards to ensure that information being provided by hospitals and doctors about their electronic records systems is accurate. To qualify for the incentive payments, doctors and hospitals must demonstrate that the systems lead to better patient care, meeting a so-called meaningful use standard by, for example, checking for harmful drug interactions.

Medicare “faces obstacles” in overseeing the electronic records incentive program “that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements,” the investigators concluded. The report was prepared by the Office of Inspector General for the Department of Health and Human Services, which oversees Medicare.

The investigators contrasted the looser management of the incentive program with the agency’s pledge to more closely monitor Medicare payments of medical claims. Medicare officials have indicated that the agency intends to move away from a “pay and chase” model, in which it tried to get back any money it has paid in error, to one in which it focuses on trying to avoid making unjustified payments in the first place.

Late Wednesday, a Medicare spokesman said in a statement: “Protecting taxpayer dollars is our top priority and we have implemented aggressive procedures to hold providers accountable. Making a false claim is a serious offense with serious consequences and we believe the overwhelming majority of doctors and hospitals take seriously their responsibility to honestly report their performance.”

The government’s investment in electronic records was authorized under the broader stimulus package passed in 2009. Medicare expects to spend nearly $7 billion over five years as a way of inducing doctors and hospitals to adopt and use electronic records. So far, the report said, the agency has paid 74, 317 health professionals and 1,333 hospitals. By attesting that they meet the criteria established under the program, a doctor can receive as much as $44,000 for adopting electronic records, while a hospital could be paid as much as $2 million in the first year of its adoption. The inspector general’s report follows earlier concerns among regulators and others over whether doctors and hospitals are using electronic records inappropriately to charge more for services, as reported by The New York Times last September, and is likely to fuel the debate over the government’s efforts to promote electronic records. Critics say the push for electronic records may be resulting in higher Medicare spending with little in the way of improvement in patients’ health. Thursday’s report did not address patient care.

Even those within the industry say the speed with which systems are being developed and adopted by hospitals and doctors has led to a lack of clarity over how the records should be used and concerns about their overall accuracy.

“We’ve gone from the horse and buggy to the Model T, and we don’t know the rules of the road. Now we’ve had a big car pileup,” said Lynne Thomas Gordon, the chief executive of the American Health Information Management Association, a trade group in Chicago. The association, which contends more study is needed to determine whether hospitals and doctors actually are abusing electronic records to increase their payments, says it supports more clarity.

Although there is little disagreement over the potential benefits of electronic records in reducing duplicative tests and avoiding medical errors, critics increasingly argue that the federal government has not devoted enough time or resources to making certain the money it is investing is being well spent.

House Republicans echoed these concerns in early October in a letter to Kathleen Sebelius, secretary of health and human services. Citing the Times article, they called for suspending the incentive program until concerns about standardization had been resolved. “The top House policy makers on health care are concerned that H.H.S. is squandering taxpayer dollars by asking little of providers in return for incentive payments,” said a statement issued at the same time by the Republicans, who are likely to seize on the latest inspector general report as further evidence of lax oversight. Republicans have said they will continue to monitor the program.

In her letter in response, which has not been made public, Ms. Sebelius dismissed the idea of suspending the incentive program, arguing that it “would be profoundly unfair to the hospitals and eligible professionals that have invested billions of dollars and devoted countless hours of work to purchase and install systems and educate staff.” She said Medicare was trying to determine whether electronic records had been used in any fraudulent billing but she insisted that the current efforts to certify the systems and address the concerns raised by the Republicans and others were adequate.

This article has been revised to reflect the following correction:

Correction: November 30, 2012

An article on Thursday about a federal report critical of Medicare’s performance in assuring accuracy as doctors and hospitals switch to electronic medical records misstated, in some copies, the timing of a statement from a Medicare spokesman in response to the report. The statement was released late Wednesday, not late Thursday.

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High & Low Finance: A Clash of Auditors in H.P. Deal and Loss

The battle over Hewlett-Packard’s claim that it was bamboozled when it bought Autonomy, a British software company, has been long on angry rhetoric and short on details about the accounting that was supposedly wrong and led to an $8.8 billion write-down.

But the eternal question asked whenever a fraud surfaces — “Where were the auditors?” — does have an answer in this case.

They were everywhere.

They were consulting. They were advising, according to one account, on strategies for “optimizing” revenue. They were investigating whether books were cooked, and they were signing off on audits approving the books that are now alleged to have been cooked. They were offering advice on executive pay. There are four major accounting firms, and each has some involvement.

Herewith a brief summary of the Autonomy dispute:

Hewlett-Packard, a computer maker that in recent years has gone from one stumble to another, bought Autonomy last year. The British company’s accounting had long been the subject of harsh criticism from some short-sellers, but H.P. evidently did not care. The $11 billion deal closed in October 2011.

Last week, H.P. said Autonomy had been cooking its books in a variety of ways. Mike Lynch, who founded Autonomy and was fired by H.P. this year, says the company’s books were fine. If the company has lost value, he says, it is because of H.P.’s mismanagement.

Autonomy was audited by the British arm of Deloitte. H.P., which is audited by Ernst & Young, hired KPMG to perform due diligence in connection with the acquisition — due diligence that presumably found no big problems with the books.

That covered three of the four big firms, so it should be no surprise that the final one, PricewaterhouseCoopers, was brought in to conduct a forensic investigation after an unnamed whistle-blower told H.P. that the books were not kosher. H.P. says the PWC investigation found “serious accounting improprieties, misrepresentation and disclosure failures.”

That would seem to make the Big Four tally two for Autonomy and two for H.P., or at least it would when Ernst approves H.P.’s annual report including the write-down.

But KPMG wants it known that it “was not engaged by H.P. to perform any audit work on this matter. The firm’s only role was to provide a limited set of non-audit-related services.” KPMG won’t say what those services were, but states, “We can say with confidence that we acted responsibly and with integrity.’

Deloitte did much more for Autonomy than audit its books, perhaps taking advantage of British rules, which are more relaxed about potential conflicts of interest than are American regulations enacted a decade ago in the Sarbanes-Oxley law. In 2010, states the company’s annual report, 44 percent of the money paid to Deloitte by Autonomy was for nonaudit services. Some of the money went for “advice in relation to remuneration,” which presumably means consultations on how much executives should be paid.

The consulting arms of the Big Four also have relationships that can be complicated. At an auditing conference this week at New York University, Francine McKenna of Forbes.com noted that Deloitte was officially a platinum-level “strategic alliance technology implementation partner” of H.P. and said she had learned of “at least two large client engagements where Autonomy and Deloitte Consulting worked together before the acquisition.” A Deloitte spokeswoman did not comment on that report.

To an outsider, making sense of this brouhaha is not easy. In a normal accounting scandal, if there is such a thing, the company restates its earnings and details how revenue was inflated or costs hidden. That has not happened here, and it may never happen. There is not even an accusation of how much Autonomy inflated its profits, but if there were, it would be a very small fraction of the $8.8 billion write-off that H.P. took. Autonomy never reported earning $1 billion in a year.

That $8.8 billion represents a write-off of much of the good will that H.P. booked when it made the deal, based on the conclusion that Autonomy was not worth nearly as much as it had paid. It says more than $5 billion of that relates to the accounting irregularities, with the rest reflecting H.P.’s low stock price and “headwinds against anticipated synergies and marketplace performance,” whatever that might mean.

Some of the accounting accusations relate to how Autonomy booked expenses. The H.P. version is that the British company made sales of hardware — personal computers it bought and resold — look like sales of valuable software. It hid some costs as marketing expenses when they should have been reported as costs of goods sold.

All that, if true, would inflate operating profit margins and growth rates for the most important part of the business. But it would not change net earnings.

Floyd Norris comments on finance and the economy at nytimes.com/economix.

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Demographic Shifts Redefine Society in South Korea

Woohae Cho for the International Herald Tribune

Assemblywoman Jasmine Lee of South Korea attended a joint wedding for 20 multicultural couples in Seoul.

SEOUL — Jasmine Lee realizes just how Korean she’s become when she breaks out in the language, forgetting that her Filipino mother on the other end of the phone can’t understand her. But she is reminded of the limits of assimilation when Koreans, impressed by her fluency, comment: “You sound more Korean than Koreans do.”

Ms. Lee, 35, who was born Jasmine Bacurnay in the Philippines, made history in April when she became the first naturalized citizen — and the first non-ethnic Korean — to win a seat in South Korea’s National Assembly. Her election reflected one of the most significant demographic shifts in the country’s modern history, a change Ms. Lee says “Koreans understand with their brain, but have yet to embrace with their heart.”

Only a decade ago, school textbooks still urged South Koreans to take pride in being of “one-blood” and “ethnically homogeneous.” Now, the country is facing the prospect of becoming a multiethnic society. While the foreign-born population is still small compared with countries with a tradition of immigration, it’s enough to challenge how South Koreans see themselves.

“It’s time to redefine a Korean,” said Kim Yi-seon, chief researcher on multiculturalism at the government-financed Korean Women’s Development Institute. “Traditionally, a Korean meant someone born to Korean parents in Korea, who speaks Korean and has Korean looks and nationality. People don’t think someone is a Korean just because he has a Korean citizenship.”

Among the factors driving this development is the influx of women from Southeast Asia who have come to marry rural South Korean men who have difficulty attracting Korean women willing to embrace country life. The number of marriage migrants grew to 211,000 last year from 127,000 in 2007, most of them women from Vietnam and other poorer Asian countries drawn to a better life in South Korea.

In industrial towns, young men from Bangladesh and Pakistan toil at jobs shunned by Koreans as too dirty and dangerous, providing cheap labor that South Korea’s export-driven economy needs to compete with China. The number of such workers almost doubled to 553,000 last year from 260,000 in 2007 — not counting those who overstay their visas and work illegally.

One of every 10 marriages in South Korea now involves a foreign spouse. Although overall numbers of schoolchildren in South Korea have been declining — to 6.7 million this year from 7.7 million in 2007 — as a result of one of the world’s lowest birth rates, the number of multiethnic students has been climbing by 6,000 a year in the same period.

“A multicultural society is not just coming; it’s already here,” Ms. Lee, a member of the governing Saenuri Party, said in an interview at her office in the National Assembly.

Still, her election exposed how far South Korea remains from that ideal, suggesting a rough road ahead as it grapples with the demographic changes.

After Ms. Lee’s election, anti-immigration activists warned that “poisonous weeds” from abroad were “corrupting the Korean bloodline” and “exterminating the Korean nation” and urged political parties to “purify” themselves by expelling Ms. Lee from the National Assembly.

Prime Minister Kim Hwang-sik has condemned such xenophobic outbursts as “pathological,” and he urged South Koreans to take the transition to a multicultural society “not as a choice, but as an imperative.”

The role of ethnicity in South Koreans’ self-image explains why they take such pride in the success of ethnic Koreans abroad, like the new president of the World Bank, the Korean-American Jim Yong Kim. It also explains why they considered it a national shame that a 23-year-old Korean-born permanent resident in the United States,  Seung-Hui Cho, killed 32 in a shooting rampage at Virginia Tech in 2007, even though he had emigrated with his family when he was 8.

Given this cultural backdrop, Korean policy makers face a difficult task integrating multiethnic families while avoiding the social and economic turmoil often blamed on immigrants elsewhere.

“They bring religious and ethnic strife to our country, where we had none before,” said Kim Ky-baek, publisher of the nationalist Web site Minjokcorea and a critic of the government’s policy of admitting and providing social benefits to foreign-born brides and migrant workers. “They create an obstacle to national unification. North Korea adheres to pure-blood nationalism, while the South is turning into a hodgepodge of mixed blood.”

This article has been revised to reflect the following correction:

Correction: November 29, 2012

An earlier version of this story described Seung Hui Cho, who killed 32 students in a 2007 shooting rampage at Virginia Tech before committing suicide, as a Korean-American citizen. While he was a permanent resident in the United States, he was not a citizen.

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The Next War: In Federal Budget Cutting, F-35 Fighter Jet Is at Risk

Luke Sharrett for The New York Times

Vice Adm. David Venlet was named to lead the Joint Strike Fighter program in 2010 after problems had left it behind schedule and over budget.

LEXINGTON PARK, Md. — The Marine version of the F-35 Joint Strike Fighter, already more than a decade in the making, was facing a crucial question: Could the jet, which can soar well past the speed of sound, land at sea like a helicopter?

Luke Sharrett for The New York Times

An F-35B, the Marine Corps version of the Joint Strike Fighter.

On an October day last year, with Lt. Col. Fred Schenk at the controls, the plane glided toward a ship off the Atlantic coast and then, its engine rotating straight down, descended gently to the deck at seven feet a second.

There were cheers from the ship’s crew members, who “were all shaking my hands and smiling,” Colonel Schenk recalled.

The smooth landing helped save that model and breathed new life into the huge F-35 program, the most expensive weapons system in military history. But while Pentagon officials now say that the program is making progress, it begins its 12th year in development years behind schedule, troubled with technological flaws and facing concerns about its relatively short flight range as possible threats grow from Asia.

With a record price tag — potentially in the hundreds of billions of dollars — the jet is likely to become a target for budget cutters. Reining in military spending is on the table as President Obama and Republican leaders in Congress look for ways to avert a fiscal crisis. But no matter what kind of deal is reached in the next few weeks, military analysts expect the Pentagon budget to decline in the next decade as the war in Afghanistan ends and the military is required to do its part to reduce the federal debt.

Behind the scenes, the Pentagon and the F-35’s main contractor, Lockheed Martin, are engaged in a conflict of their own over the costs. The relationship “is the worst I’ve ever seen, and I’ve been in some bad ones,” Maj. Gen. Christopher Bogdan of the Air Force, a top program official, said in September. “I guarantee you: we will not succeed on this if we do not get past that.”

In a battle that is being fought on other military programs as well, the Pentagon has been pushing Lockheed to cut costs much faster while the company is fighting to hold onto a profit. “Lockheed has seemed to be focused on short-term business goals,” Frank Kendall, the Pentagon’s top weapons buyer, said this month. “And we’d like to see them focus more on execution of the program and successful delivery of the product.”

The F-35 was conceived as the Pentagon’s silver bullet in the sky — a state-of-the art aircraft that could be adapted to three branches of the military, with advances that would easily overcome the defenses of most foes. The radar-evading jets would not only dodge sophisticated antiaircraft missiles, but they would also give pilots a better picture of enemy threats while enabling allies, who want the planes, too, to fight more closely with American forces.

But the ambitious aircraft instead illustrates how the Pentagon can let huge and complex programs veer out of control and then have a hard time reining them in. The program nearly doubled in cost as Lockheed and the military’s own bureaucracy failed to deliver on the most basic promise of a three-in-one jet that would save taxpayers money and be served up speedily.

Lockheed has delivered 41 planes so far for testing and initial training, and Pentagon leaders are slowing purchases of the F-35 to fix the latest technical problems and reduce the immediate costs. A helmet for pilots that projects targeting data onto its visor is too jittery to count on. The tail-hook on the Navy jet has had trouble catching the arresting cable, meaning that version cannot yet land on carriers. And writing and testing the millions of lines of software needed by the jets is so daunting that General Bogdan said, “It scares the heck out of me.”

With all the delays — full production is not expected until 2019 — the military has spent billions to extend the lives of older fighters and buy more of them to fill the gap. At the same time, the cost to build each F-35 has risen to an average of $137 million from $69 million in 2001.

The jets would cost taxpayers $396 billion, including research and development, if the Pentagon sticks to its plan to build 2,443 by the late 2030s. That would be nearly four times as much as any other weapons system and two-thirds of the $589 billion the United States has spent on the war in Afghanistan. The military is also desperately trying to figure out how to reduce the long-term costs of operating the planes, now projected at $1.1 trillion.

“The plane is unaffordable,” said Winslow T. Wheeler, an analyst at the Project on Government Oversight, a nonprofit group in Washington.

Todd Harrison, an analyst at the Center for Strategic and Budgetary Assessments, a research group in Washington, said Pentagon officials had little choice but to push ahead, especially after already spending $65 billion on the fighter. “It is simultaneously too big to fail and too big to succeed,” he said. “The bottom line here is that they’ve crammed too much into the program. They were asking one fighter to do three different jobs, and they basically ended up with three different fighters.”

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Well: Weight Loss Surgery May Not Combat Diabetes Long-Term

Weight loss surgery, which in recent years has been seen as an increasingly attractive option for treating Type 2 diabetes, may not be as effective against the disease as it was initially thought to be, according to a new report. The study found that many obese Type 2 diabetics who undergo gastric bypass surgery do not experience a remission of their disease, and of those that do, about a third redevelop diabetes within five years of their operation.

The findings contrast with the growing perception that surgery is essentially a cure for Type II diabetes. Earlier this year, two widely publicized studies reported that surgery worked better than drugs, diet and exercise in causing a remission of Type 2 diabetes in overweight people whose blood sugar was out of control, leading some experts to call for greater use of surgery in treating the disease. But the studies were small and relatively short, lasting under two years.

The latest study, published in the journal Obesity Surgery, tracked thousands of diabetics who had gastric bypass surgery for more than a decade. It found that many people whose diabetes at first went away were likely to have it return. While weight regain is a common problem among those who undergo bariatric surgery, regaining lost weight did not appear to be the cause of diabetes relapse. Instead, the study found that people whose diabetes was most severe or in its later stages when they had surgery were more likely to have a relapse, regardless of whether they regained weight.

“Some people are under the impression that you have surgery and you’re cured,” said Dr. Vivian Fonseca, the president for medicine and science for the American Diabetes Association, who was not involved in the study. “There have been a lot of claims about how wonderful surgery is for diabetes, and I think this offers a more realistic picture.”

The findings suggest that weight loss surgery may be most effective for treating diabetes in those whose disease is not very advanced. “What we’re learning is that not all diabetic patients do as well as others,” said Dr. David E. Arterburn, the lead author of the study and an associate investigator at the Group Health Research Institute in Seattle. “Those who are early in diabetes seem to do the best, which makes a case for potentially earlier intervention.”

One of the strengths of the new study was that it involved thousands of patients enrolled in three large health plans in California and Minnesota, allowing detailed tracking over many years. All told, 4,434 adult diabetics were followed between 1995 and 2008. All were obese, and all underwent Roux-en-Y operations, the most popular type of gastric bypass procedure.

After surgery, about 68 percent of patients experienced a complete remission of their diabetes. But within five years, 35 percent of those patients had it return. Taken together, that means that most of the subjects in the study, about 56 percent — a figure that includes those whose disease never remitted — had no long-lasting remission of diabetes after surgery.

The researchers found that three factors were particularly good predictors of who was likely to have a relapse of diabetes. If patients, before surgery, had a relatively long duration of diabetes, had poor control of their blood sugar, or were taking insulin, then they were least likely to benefit from gastric bypass. A patient’s weight, either before or after surgery, was not correlated with their likelihood of remission or relapse.

In Type 2 diabetes, the beta cells that produce insulin in the pancreas tend to wear out as the disease progresses, which may explain why some people benefit less from surgery. “If someone is too far advanced in their diabetes, where their pancreas is frankly toward the latter stages of being able to produce insulin, then even after losing a bunch of weight their body may not be able to produce enough insulin to control their blood sugar,” Dr. Arterburn said.

Nonetheless, he said it might be the case that obese diabetics, even those whose disease is advanced, can still benefit from gastric surgery, at least as far as their quality of life and their risk factors for heart disease and other complications are concerned.

“It’s not a surefire cure for everyone,” he said. “But almost universally, patients lose weight after weight loss surgery, and that in and of itself may have so many health benefits.”

Read More..

Well: Weight Loss Surgery May Not Combat Diabetes Long-Term

Weight loss surgery, which in recent years has been seen as an increasingly attractive option for treating Type 2 diabetes, may not be as effective against the disease as it was initially thought to be, according to a new report. The study found that many obese Type 2 diabetics who undergo gastric bypass surgery do not experience a remission of their disease, and of those that do, about a third redevelop diabetes within five years of their operation.

The findings contrast with the growing perception that surgery is essentially a cure for Type II diabetes. Earlier this year, two widely publicized studies reported that surgery worked better than drugs, diet and exercise in causing a remission of Type 2 diabetes in overweight people whose blood sugar was out of control, leading some experts to call for greater use of surgery in treating the disease. But the studies were small and relatively short, lasting under two years.

The latest study, published in the journal Obesity Surgery, tracked thousands of diabetics who had gastric bypass surgery for more than a decade. It found that many people whose diabetes at first went away were likely to have it return. While weight regain is a common problem among those who undergo bariatric surgery, regaining lost weight did not appear to be the cause of diabetes relapse. Instead, the study found that people whose diabetes was most severe or in its later stages when they had surgery were more likely to have a relapse, regardless of whether they regained weight.

“Some people are under the impression that you have surgery and you’re cured,” said Dr. Vivian Fonseca, the president for medicine and science for the American Diabetes Association, who was not involved in the study. “There have been a lot of claims about how wonderful surgery is for diabetes, and I think this offers a more realistic picture.”

The findings suggest that weight loss surgery may be most effective for treating diabetes in those whose disease is not very advanced. “What we’re learning is that not all diabetic patients do as well as others,” said Dr. David E. Arterburn, the lead author of the study and an associate investigator at the Group Health Research Institute in Seattle. “Those who are early in diabetes seem to do the best, which makes a case for potentially earlier intervention.”

One of the strengths of the new study was that it involved thousands of patients enrolled in three large health plans in California and Minnesota, allowing detailed tracking over many years. All told, 4,434 adult diabetics were followed between 1995 and 2008. All were obese, and all underwent Roux-en-Y operations, the most popular type of gastric bypass procedure.

After surgery, about 68 percent of patients experienced a complete remission of their diabetes. But within five years, 35 percent of those patients had it return. Taken together, that means that most of the subjects in the study, about 56 percent — a figure that includes those whose disease never remitted — had no long-lasting remission of diabetes after surgery.

The researchers found that three factors were particularly good predictors of who was likely to have a relapse of diabetes. If patients, before surgery, had a relatively long duration of diabetes, had poor control of their blood sugar, or were taking insulin, then they were least likely to benefit from gastric bypass. A patient’s weight, either before or after surgery, was not correlated with their likelihood of remission or relapse.

In Type 2 diabetes, the beta cells that produce insulin in the pancreas tend to wear out as the disease progresses, which may explain why some people benefit less from surgery. “If someone is too far advanced in their diabetes, where their pancreas is frankly toward the latter stages of being able to produce insulin, then even after losing a bunch of weight their body may not be able to produce enough insulin to control their blood sugar,” Dr. Arterburn said.

Nonetheless, he said it might be the case that obese diabetics, even those whose disease is advanced, can still benefit from gastric surgery, at least as far as their quality of life and their risk factors for heart disease and other complications are concerned.

“It’s not a surefire cure for everyone,” he said. “But almost universally, patients lose weight after weight loss surgery, and that in and of itself may have so many health benefits.”

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App Smart: Apps for Home Repairs for the Handy and the Less So

With the holiday season approaching, the last thing you need is to worry about home repairs. And as rain and cold try to penetrate your house, it’s inevitable that something will go awry — a pipe will burst or that warped window frame will let in too much of the cold. That’s my problem right now — a window frame in my bathroom just won’t seal against the breeze (a minor problem, certainly, considering the damage from Hurricane Sandy, but a problem that is crying to be fixed). I could try to repair it myself, but I’m not too confident in working with aluminum windows, so I may end up calling a professional.

Multi Measures HD for iPad can become a spirit level, a surface level, a ruler, a protractor, a plumb bob and more.

The Finding Home & Hardware app locates suppliers.

Tips for fixing frozen pipes on wikiHow.

For issues like this, or even just to while away hours doing some D.I.Y. research, there are many apps to help.

If you find yourself struggling to repair something and really need a handyman, a simple way to find a suitable one nearby is Yelp’s app, free on iOS and Android. Yelp, often a go-to for restaurant advice, works for home repair experts, too. Type “handyman” or “plumber” into the app’s “Filter” boxes, along with location, and it will show a list of people and businesses. The advantage of Yelp is the ability to see how previous clients rated the quality of work. Read several reviews, as people’s experiences and expectations can vary.

For a more controlled experience, try RedBeacon (free on iOS and Android), a popular app with many positive reviews. RedBeacon covers only certain metropolitan areas across the United States, however, and may not help everyone. Unlike Yelp’s more open platform, RedBeacon has a list of approved businesses and tries to match the task at hand with the right worker. The app operates through a “request” system: users enter job details, and can provide photos and video. The system also has reviews, and can help schedule a time for the work.

More confident do-it-yourselfers may tackle a problem on their own. If it’s urgent, like a broken water heater or even water damage after a leak, the WikiHow How To and DIY Survival guide (free on Android and iOS) might be useful. Type in a few key words about the problem into the app’s Search page and the guide will return some advice. Its information pages are clear and well laid-out. They begin with an introductory description, then offer a list of steps to follow. The app displays the necessary tools and items, and includes tips and warnings (like shutting off the electricity before trying to fix a water heater). When you’re done with the home repair tasks, this app can teach self-defense tricks or help you fix your car. But it’s not an exhaustive reference on home upkeep or emergency repairs.

Some apps can turn a smartphone into an actual work tool. One app for iOS devices is Multi Measures ($1, or $2 for an “HD” iPad version). The app’s interfaces are attractive and easy to read, and it offers a long list of measurement options that use the device’s sensors. It can become a spirit level, a surface level, a ruler, a protractor, a plumb bob and more. It even has a decibel meter to measure volume, and a teslameter, which measures magnetic fields. This last option turns the device into a metal detector, which could be useful if you’re trying to find buried treasure, or just nailheads that show where the studs are in your walls.

The Smart Tools app is roughly equivalent to Multi Measures, on Android, for $2.50. And some free apps for iOS and Android promise similar features (sometimes separately — for example, Smart Protractor for angles, free on Android, or Dual Level, free on iOS). The apps’ quality can vary significantly, but they cost nothing to download and test-drive.

Finally, when it comes to buying supplies, an app like Finding HOME & Hardware ($1 on iOS and Android) is invaluable. It shows nearby hardware stores that meet your needs.

Happy D.I.Y.-ing. (Or, at least, I hope your apps find you an efficient and cheap plumber!)

Quick Calls

For smartphone or tablet users who dislike the map services from Apple and Google, Nokia’s Here app is a new, free alternative. It is available on iOS now and will be on Android devices later. You may prefer its clean, elegant design to the alternatives. ... In time for holiday shopping, Amazon now has an Android tablet-optimized version of its free Amazon Mobile shopping app ready, with one-click purchase options.

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U.S. Is Weighing Stronger Action in Syrian Conflict

Francisco Leong/Agence France-Presse — Getty Images

Rebels in northern Syria celebrated on Wednesday next to what was reported to be a government fighter jet.

WASHINGTON — The Obama administration, hoping that the conflict in Syria has reached a turning point, is considering deeper intervention to help push President Bashar al-Assad from power, according to government officials involved in the discussions.

While no decisions have been made, the administration is considering several alternatives, including directly providing arms to some opposition fighters.

The most urgent decision, likely to come next week, is whether NATO should deploy surface-to-air missiles in Turkey, ostensibly to protect that country from Syrian missiles that could carry chemical weapons. The State Department spokeswoman, Victoria Nuland, said Wednesday that the Patriot missile system would not be “for use beyond the Turkish border.”

But some strategists and administration officials believe that Syrian Air Force pilots might fear how else the missile batteries could be used. If so, they could be intimidated from bombing the northern Syrian border towns where the rebels control considerable territory. A NATO survey team is in Turkey, examining possible sites for the batteries.

Other, more distant options include directly providing arms to opposition fighters rather than only continuing to use other countries, especially Qatar, to do so. A riskier course would be to insert C.I.A. officers or allied intelligence services on the ground in Syria, to work more closely with opposition fighters in areas that they now largely control.

Administration officials discussed all of these steps before the presidential election. But the combination of President Obama’s re-election, which has made the White House more willing to take risks, and a series of recent tactical successes by rebel forces, one senior administration official said, “has given this debate a new urgency, and a new focus.”

The outcome of the broader debate about how heavily America should intervene in another Middle Eastern conflict remains uncertain. Mr. Obama’s record in intervening in the Arab Spring has been cautious: While he joined in what began as a humanitarian effort in Libya, he refused to put American military forces on the ground and, with the exception of a C.I.A. and diplomatic presence, ended the American role as soon as Col. Muammar el-Qaddafi was toppled.

In the case of Syria, a far more complex conflict than Libya’s, some officials continue to worry that the risks of intervention — both in American lives and in setting off a broader conflict, potentially involving Turkey — are too great to justify action. Others argue that more aggressive steps are justified in Syria by the loss in life there, the risks that its chemical weapons could get loose, and the opportunity to deal a blow to Iran’s only ally in the region. The debate now coursing through the White House, the Pentagon, the State Department and the C.I.A. resembles a similar one among America’s main allies.

“Look, let’s be frank, what we’ve done over the last 18 months hasn’t been enough,” Britain’s prime minister, David Cameron, said three weeks ago after visiting a Syrian refugee camp in Jordan. “The slaughter continues, the bloodshed is appalling, the bad effects it’s having on the region, the radicalization, but also the humanitarian crisis that is engulfing Syria. So let’s work together on really pushing what more we can do.” Mr. Cameron has discussed those options directly with Mr. Obama, White House officials say.

France and Britain have recognized a newly formed coalition of opposition groups, which the United States helped piece together. So far, Washington has not done so.

American officials and independent specialists on Syria said that the administration was reviewing its Syria policy in part to gain credibility and sway with opposition fighters, who have seized key Syrian military bases in recent weeks.

“The administration has figured out that if they don’t start doing something, the war will be over and they won’t have any influence over the combat forces on the ground,” said Jeffrey White, a former Defense Intelligence Agency intelligence officer and specialist on the Syria military. “They may have some influence with various political groups and factions, but they won’t have influence with the fighters, and the fighters will control the territory.”

Jessica Brandt contributed reporting from Cambridge, Mass.

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Facebook Gifts Urges Users to Shop While They Share

SAN FRANCISCO — Facebook is already privy to its users’ e-mail addresses, wedding pictures and political beliefs. Now the company is nudging them to share a bit more: credit card numbers and offline addresses.

James Best Jr./The New York Times

Facebook Gifts is a service that prompts users to buy things for friends on the social network.

Sharing Even More

What do you think about Facebook’s plan to have users buy gifts for their friends through the site using their credit cards?

A screenshot of Facebook Gifts.

The nudge comes from a new Facebook service called Gifts. It allows Facebook users — only in the United States for now — to buy presents for their friends on the social network. On offer are items as varied as spices from Dean & DeLuca, pajamas from BabyGap and subscriptions to Hulu Plus, the video service. This week Facebook added iTunes gift cards.

The gift service is part of an aggressive moneymaking push aimed at pleasing Facebook’s investors after the company’s dismal stock market debut. Facebook has stepped up mobile advertising and is starting to customize the marketing messages it shows to users based on their Web browsing outside Facebook.

Those efforts seem to have brought some relief to Wall Street. Analysts issued more bullish projections for the company in recent days, and the stock was up 49 percent from its lowest point, closing Tuesday at $26.15, although that is still well below the initial offering price of $38. The share price has been buoyed in part by the fact that a wave of insider lockup periods expired without a flood of shares hitting the market.

To power the Gifts service, Facebook rented a warehouse in South Dakota and created its own software to track inventory and shipping. It will not say how much it earns from each purchase made through Gifts, though merchants that have a similar arrangement with Amazon.com give it a roughly 15 percent cut of sales.

If it catches on, the service would give Facebook a toehold in the more than $200 billion e-commerce market. Much more important, it would let the company accumulate a new stream of valuable personal data and use it to refine targeted advertisements, its bread and butter. The company said it did not now use data collected through Gifts for advertising purposes, but could not rule it out in the future.

“The hard part for Facebook was aggregating a billion users. Now it’s more about how to monetize those users without scaring them away,” said Colin Sebastian, an analyst with Robert W. Baird.

He added: “Gifts should also contribute more to Facebook’s treasure trove of user data, which has the benefit of a virtuous cycle, driving more personalization of the site, leading to better and more targeted ads, which improves overall monetization.”

Facebook already collects credit card information from users who play social games on its site. But they are a limited constituency, and a wider audience may be persuaded to buy a gift when Facebook reminds them that a friend is expecting a baby or a cousin is approaching her 40th birthday.

The Gifts service, which grew out of Facebook’s acquisition of a mobile application called Karma, was introduced in September and expanded earlier this month on the eve of the holiday shopping season.

Magnolia Bakery, based in New York, was among Facebook’s early partners for Gifts. Its vice president for public relations, Sara Gramling, said the company had sold roughly 200 packages of treats since then. She counted it as a marketing success. The bakery, which gained fame thanks to “Sex and the City,” had only recently begun shipping its goods. “It was a great opportunity to expand our network,” she said.

Magnolia Bakery isn’t exactly catering to the masses. A half-dozen cupcakes cost $35, plus about $12 for shipping. Facebook, Ms. Gramling said, takes care of the billing. The bakery is eyeing Facebook’s global reach, too, as it opens outlets internationally, especially in the Middle East.

One of the appeals of Facebook Gifts is the ease of making a purchase. Facebook users are nudged to buy a gift (a gift-box icon pops up) for Facebook friends on their birthdays. They are offered a vast menu to choose from: beer glasses, cake pops, quilts, marshmallows, magazine subscriptions and donations to charity. They are asked to choose a greeting card. Then they are asked for credit card details. Facebook says it stores that credit card information, unless users remove it after making a purchase.

Facebook has declined to say how many users have bought gifts, only that among those who have, the average purchase is $25.

David Streitfeld contributed reporting.

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Amid Hurricane Sandy, a Race to Get a Liver Transplant

It was the best possible news, at the worst possible time.

The phone call from the hospital brought the message that Dolores and Vin Dreeland had long hoped for, ever since their daughter Natalia, 4, had been put on the waiting list for a liver transplant. The time had come.

They bundled her into the car for the 50-mile trip from their home in Long Valley, N.J., to NewYork-Presbyterian Morgan Stanley Children’s Hospital in Manhattan. But it soon seemed that this chance to save Natalia’s life might be just out of reach.

The date was Sunday, Oct. 28, and Hurricane Sandy, the worst storm to hit the East Coast in decades, was bearing down on New York. Airports and bridges would soon close, but the donated organ was in Nevada, five hours away. The time window in which a plane carrying the liver would be able to land in the region was rapidly closing.

In a hospital room, Natalia watched cartoons. Her parents watched the clock, and the weather. “Our anxiety was through the roof,” Mrs. Dreeland said. “It just made your stomach into knots.”

The Dreelands, who are in their 60s, became Natalia’s foster parents in 2008 when she was 7 months old, and adopted her just before she turned 2. They have another adopted daughter, Dorothy Jane, who is 17.

Natalia is a “smart little cookie” who loves school and dressing up Alice, her favorite doll, her mother said. At age 3, Natalia used the word “discombobulated” correctly, Mr. Dreeland said.

Natalia’s health problems date back several years. Her gallbladder was taken out in 2010, and about half her liver was removed in 2011. The underlying problem was a rare disease, Langerhans cell histiocytosis. It causes a tremendous overgrowth of a type of cell in the immune system and can damage organs. Drugs can sometimes keep it in check, but they did not work for Natalia.

In her case, the disease struck the bile ducts, which led to progressive liver damage. “She would have eventually gone into liver failure,” said Dr. Nadia Ovchinsky, a pediatric liver transplant specialist at NewYork-Presbyterian. “And she demonstrated some signs of early liver failure.”

The only hope was a transplant.

Dr. Tomoaki Kato, Natalia’s surgeon, knew that the liver in Nevada was a perfect match for Natalia in the two criteria that matter most: blood type and size. The deceased donor was 2 years old, and though Natalia is nearly 5, she is small for her age. Scar tissue from her previous operations would have made it very difficult to fit a larger organ into her abdomen.

Though Dr. Kato had considered transplanting part of an adult liver into Natalia, a complete organ from a child would be far better for her. But healthy organs from small children do not often become available, Dr. Kato said. This was a rare opportunity, and he was determined to seize it.

But as the day wore on, the odds for Natalia grew slimmer. The operation in Nevada to remove the liver was delayed several times.

At many hospitals, surgery to remove donor organs is done at the end of the day, after all regularly scheduled operations. The Nevada hospital had a busy surgical schedule that day, made worse by a trauma case that took priority.

At the hospital in New York, Tod Brown, an organ procurement coordinator, had alerted a charter air carrier that a flight from Nevada might be needed. That company in turn contacted West Coast carriers to pick up the donated liver and fly it to New York.

Initially, two carriers agreed, but then backed out. Several other charter companies also declined.

Mr. Brown told Dr. Kato that they might have to decline the organ. Dr. Kato, soft-spoken but relentless, said, “Find somebody who can fly.”

Dr. Kato used to work in Miami, where pilots found ways to bypass hurricanes to deliver organs. Even during Hurricane Katrina, his hospital performed transplants.

“I asked the transplant coordinators to just keep pushing,” he said.

Mr. Brown said, “Dr. Kato knew he was going to get that organ, one way or another.”

As the trajectory of the storm became clearer, one of the West Coast charter companies agreed to attempt the flight. The plan was to land at the airport in Teterboro, N.J. The backup was Newark airport, and the second backup was Albany, from where an ambulance would finish the trip.

The timing was critical: organs deteriorate outside the body, and ideally a liver should be transplanted within 12 hours of being removed.

Early Monday, as the storm whirled offshore, the plane landed at Teterboro. Soon a nurse rushed to tell the Dreelands that she had just seen an ambulance with lights and sirens screech up to the hospital. Someone had jumped out carrying a container.

At about 5 a.m., the couple kissed Natalia and saw her wheeled off to the operating room.

Three weeks later, she is back home, on the mend. The complicated regimen of drugs that transplant patients need is tough on a child, but she is getting through it, her father said.

Recently, Mr. Dreeland said, he found himself weeping uncontrollably during a church service for the family of the child who had died. “Their child gave my child life,” he said.

Though only time will tell, because the histiocytosis appeared limited to Natalia’s bile ducts and had not affected other organs, her doctors say there is a good chance that the transplant has cured her.

This article has been revised to reflect the following correction:

Correction: November 28, 2012

Because of an editing error, a picture caption with an article on Tuesday about a girl who received a liver transplant during Hurricane Sandy misspelled the surname of the girl’s family. As the article correctly noted, it is Dreeland, not Vreeland.

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