old on a ranked list produced by the state's Health Services Commission. In the first draft list, issued in 1990, the state ranked health services according to a crude cost-effectiveness measure.

The principle seems rational. "If you stop doing things that don't work and do things that do work to more people, the average health of the population should go up," says Kaplan, one of the originators of the scheme. "The Oregon plan for the first time sees the outcome as part of the solution and says, 'We want to get health for our money.'''

But any kind of rationing is contro­versial, and the draft was widely criti­cized. According to Hadorn, it failed to allow for the "rule of rescue": the physician's moral obligation to save life. Thus, appendectomy, which usually saves lives, fell below splints for jaw disorders on the list. Dental caps for pulp exposure were assigned almost as high a priority as life-saving surgery for ectopic pregnancy.

In response to the criticism, the state revised its priority list last year. The new version ranks procedures, grouped into categories, according to benefit alone. Cost was not considered, except in some "by hand" adjustments made at

the end. As before, only treatments above a cutoff point would be funded through Medicaid.

Oregon is now waiting for a bureau­cratic thumbs-up for its plan-techni­cally, a waiver of Medicaid rules-from the federal Health Care Financing Ad­ministration. But in an election year the White House is fearful of appearing in­sensitive, especially as congressional Democrats oppose the Oregon experi­ment. The Washington rumor mill has it that the waiver request will be denied and the Oregon plan shot down.

Even the revised list is being criti­cized. Oregon held numerous commu­nity meetings while it was developing its proposal, but "although the com­missioners felt constrained to reflect community values, it is not clear they succeeded," says Wiener, who is wary of the approach. Physicians on the Ore­gon commission often had to guess at the benefits of procedures, he charges. And Wiener questions whether the ap­proach would be politically workable in a "culturally more diverse state."

Others are more optimistic. "Oregon tried to do the right thing," says David M. Eddy, an authority on health care as­sessment, who is based in Jackson,

Is It History or Just E-Mail?

Wyo. Eddy favors cost-effectiveness analysis, but he acknowledges there are insufficient data to compare all medical services. Eddy now advocates building on a list similar to that in Oregon but refining it by performing cost-effective­ness analyses on narrow categories of treatments that are near the cutoff threshold or suspected of falling on the wrong side of the threshold.

Other ways to ration care are also be­ing developed. According to Hadorn, the key question is: "What sort of treat­ments benefit what sort of patients?" Hadorn insists that doctors make such judgments every day. "It does not need to be a long, complicated process," he says. Hadorn favors using a "jury" of ex­perts and consumer representatives to evaluate formally evidence for efficacy. With a federal grant, he is putting the idea into practice by assessing treat­ments for congestive heart failure.

Eventually, Hadorn believes, both Medicaid and private insurance will have to develop a "basic benefits plan" of treatments that have proved cost­effective. "Clearly, there's a need to sep­arate the wheat from the chaff," he says. "The days when insurers would pay for everything are over." - Tim Beardsley

C omputers can act in microseconds, but the law takes a little longer. So the nonprofit National Secu­rity Archive in Washington, D.C., discovered when

they filed suit in early 1 989 to protect from destruction megabytes of data compiled by the Reagan White House staff. A federal judge was expected to issue a ruling in April ordering the current administration to provide an in­ventory and samples of backed-up data to the archive's lawyers, who contend that the information must be protected under the Federal Records Act. At issue is whether electronic mail constitutes official government records or whether it is simply digital doodling.

filed for archiving. By implication, anything not printed would be considered ephemeral.

Michael Tankersley, a lawyer at Public Citizen, an advoca­cy group involved in the case, argues that such a policy leaves individuals with enormous latitude to deny their de­liberations to posterity simply by failing to print them out. Furthermore, he points out, the National Security Council allocated only two printers to more than 150 people.

Although high-profile operatives such as Oliver North provide the juiciest potential electronic tidbits, E-mail inhab­its a similar limbo at other federal agencies, Tankersley says. At the Department of Energy, for example, the elec­tronic version of officials' personal calendars is considered a record, but E-mail conversations are explicitly unofficial.

The archive, a private group that helps make govern­ment information dealing with national security available to scholars, discovered on the eve of George Bush's inau­guration that dozens of computer backup tapes-among them ones containing memos from the Iran-Contra fias­co-were about to be erased. Citing federal law that pro­hibits the wholesale destruction of records, the archive obtained a temporary order preserving the material. The fate of the tapes has been in litigation ever since.

If these memos and E-mail messages were on paper, ex­plains archive general counsel Sheryl Walter, there would be no question that most of them should be preserved. The White House, however, has argued that the docu­ments have no substantive value and fall into the same "nonrecord" category as telephone message slips.

In support of its position, the government cites a policy statement, first committed to paper after the lawsuit was filed, instructing officials that any electronic document at­taining "record" status should be printed out on paper and

2 0 SCIENTIFIC AMERICAN May 1992

Indeed, according to David Bearman of the University of Pittsburgh, the problem goes far beyond the federal gov­ernment. As business is increasingly transacted by com­puter, the status of digital documents waxes problematic. Some heavy users of E-mail save everything they send or receive; others discard it all. Managers everywhere, Bear­man says, have yet to come to grips with the issue. E-mail and other computerized data are '�ust out there," he com­ments. "Managers don't know how they're structured, how they're managed or what happens after they use them."

If Tankersley and Walter get their way, a judge might rule by the end of the year that at least some White House E-mail merits the same preservation as the administra­tion's voluminous paper files. In general, Bearman ob­serves, the official or unofficial status of electronic mes­sages will have to be decided by "a larger cultural consen­sus rather than a narrow legal ruling." -Paul Wallich

© 1992 SCIENTIFIC AMERICAN, INC