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.

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State of the Art: Tablets Are Hot Holiday Gifts, but Which One to Buy? — Review

From left: J. Emilio Flores for The New York Times, Jim Wilson/The New York Times, Everett Kennedy Brown/European Pressphoto Agency

From left, the Kindle PaperWhite, the iPad Mini and the  Nexus 7.

The other day, I joined NPR for a segment about high-tech holiday gifts. I was ready for the calls from listeners. I’d brushed up on cameras, phones, laptops, music players and game consoles. I was prepared to talk about limiting screen time, digital addiction, cyberbullying. I knew where to get the best deals.

But all six callers had the same question: “What tablet should I get?”

There were variations, of course. “— for my kid?” “— for my elderly father?” “— just for reading?” “— for not much money?” But in general, it was clear: the gadget most likely to be found under the tree this year is thin, battery-powered and flat.

No wonder people are confused. The marketplace has gone tablet-crazy. There’s practically a different model for every man, woman and child.

There’s the venerable iPad, of course. And now the iPad Mini. There are new tablets from Google, also in small and large. There are Samsung’s Note tablets in a variety of sizes, with styluses. There are $200 touch-screen color e-book/video players. There’s a new crop of black-and-white e-book readers. There are stunningly cheap plastic models you’ve never heard of. There are tablets for children (and I don’t mean baby aspirin).

So how are you, the confused consumer, supposed to keep tabs on all these tablets? By taking this handy tour through the jungle of tablets 2012. Keep hands and feet inside the tram at all times.

DIRT-CHEAP KNOCKOFFS You can find no-name tablets for $100 or even less. You can also find mystery-brand Chinese tablets in toy stores, marketed to children.

Don’t buy them. They don’t have the apps, the features, the polish or the pleasure of the nicer ones. The junk drawer is already calling their names.

E-BOOK READERS The smallest, lightest, least expensive, easiest to read tablets are the black-and-white e-book readers. If the goal is simply reading — and not, say, watching movies or playing games — these babies are pure joy.

Don’t bother with the lesser brands; if you’re going to get locked into one company’s proprietary, copy-protected book format, you’ll reduce your chances of library obsolescence if you stick with Amazon or Barnes & Noble.

Each company offers a whole bunch of models. But on the latest models, the page background lights up softly, so that you can read in the dark without a flashlight. (These black-and-white models also look fantastic in direct sun — now you get the best of both lighting conditions.)

The one you want is the Kindle PaperWhite ($120), whose illumination is more even and pleasant than the equivalent Nook’s.

Of course, plain, no-touch, no-light Kindles, with ads on the screen saver, start as low as $70. But the light and the touch-screen are really worth having.

COLOR E-READERS/PLAYERS Amazon and B.& N. each sell a seven-inch tablet that, functionally, lands somewhere between an e-book reader and an iPad. They have beautiful, high-definition touch-screens. They play music, TV shows, movies and e-books. They can surf the Web. They even run a few handpicked Android apps like Netflix and Angry Birds.

They’re nowhere near as capable as full-blown, computerlike tablets of the iPad/Nexus ilk, mainly because there are so few apps, accessories and add-ons. But they cost $200; you’re paying only a fraction of the price.

The big two here are, once again, Amazon and B.& N. If you’re not already locked in to one of those companies’ books and videos because you owned a previous model, the Nook HD is the one to get. It’s much smaller and lighter than the Kindle Fire HD. It has a much sharper screen. And the $200 price includes a wall charger (the Fire doesn’t) and no ads (the Fire does). Or get the classy Google Nexus 7, also $200. Although its book/music/movie catalog is far smaller, its Android app catalog is far larger (but see “iPad versus Android,” below).

BIG COLOR READERS/PLAYERS This year, both Amazon and B.& N. have introduced jumbo-screen (9-inch) versions of their HD tablets. Here again, B.& N. offers a better value than its 9-inch Kindle Fire HD rival. For $270, the Nook HD+ offers a sharper screen, lighter weight, no ads, a memory-card slot and a wall charger.

E-mail: pogue@nytimes.com

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Hacking Report Criticizes Murdoch Newspaper and British Press Standards

LONDON — The leader of a major inquiry into the standards of British newspapers triggered by the phone hacking scandal offered an excoriating critique of the press as a whole on Thursday, saying it displayed “significant and reckless disregard for accuracy,” and urged the press to form an independent regulator to be underpinned by law.

Dan Kitwood/Getty Images

Lord Justice Sir Brian Leveson on Thursday with his inquiry on press standards.

The report singled out Rupert Murdoch’s defunct tabloid The News of the World for sharp criticism.

“Too many stories in too many newspapers were the subject of complaints from too many people with too little in the way of titles taking responsibility, or considering the consequences for the individuals involved,” the head of the inquiry, Lord Justice Sir Brian Leveson, said in a 46-page summary of the findings in his long-awaited, 1,987-page report published in four volumes.

“The ball moves back into the politicians’ court,” Sir Brian said, referring to what form new and tighter regulations should take. “They must now decide who guards the guardians.”

The report was published after some 337 witnesses testified in person in 9 months of hearings that sought to unravel the close ties between politicians, the press and the police, reaching into what were depicted as an opaque web of links and cross-links within the British elite as well as a catalog of murky and sometimes unlawful practices within the newspaper industry.

“This inquiry has been the most concentrated look at the press this country has ever seen,” Sir Brian said after the report was made public.

But in a first reaction, Prime Minister David Cameron resisted the report’s recommendation that a new form of press regulation should be underpinned by laws, telling lawmakers that they “should be wary” of “crossing the Rubicon” by enacting legislation with the potential to limit free speech and free expression.

Mr. Cameron’s remarks drew immediate criticism from the leader of the Labour opposition, Ed Miliband, who said Sir Brian’s proposals should be accepted in their entirety.

Mr. Cameron ordered the Leveson Inquiry in July, 2011, as the phone hacking scandal at The News of the World blossomed into broad public revulsion with reports that the newspaper had ordered the interception of voice mail messages left on the cellphone of Milly Dowler, a British teenager who was abducted in 2002 and later found murdered. Sir Brian said there had been a “failure of management and compliance” at the 168-year-old News of the World, which Mr. Murdoch closed in July, 2011, accusing it of a “general lack of respect for individual privacy and dignity.”

“It was said that The News of the World had lost its way in relation to phone hacking,” the summary said. “Its casual attitude to privacy and the lip service it paid to consent demonstrated a far more general loss of direction.”

Speaking after the report was published, Sir Brian said that while the British press held a “privileged and powerful place in our society,” its “responsibilities have simply been ignored.”

“A free press in a democracy holds power to account. But, with a few honorable exceptions, the U.K. press has not performed that vital role in the case of its own power.”

“The press needs to establish a new regulatory body which is truly independent of industry leaders and of government and politicians,” he said. “Guaranteed independence, long-term stability and genuine benefits for the industry cannot be realized without legislation,” he said, adding: “This is not and cannot reasonably or fairly be characterized as statutory regulation of the press.”

In the body of the exhaustive report, reprising at length the testimony of many of the witnesses who spoke at the hearings, the document discusses press culture and ethics; explores the press’s attitude toward the subjects of its stories; and discusses the cozy relationship between the press and the police, and the press and politicians.

John F. Burns, Sandy Lark Turner and Sandy Macaskill contributed reporting.

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Ex-NASA Scientist’s Data Fears Come True

In 2007, Robert M. Nelson, an astronomer, and 27 other scientists at the Jet Propulsion Laboratory sued NASA arguing that the space agency’s background checks of employees of government contractors were unnecessarily invasive and violated their privacy rights.

Privacy advocates chimed in as well, contending that the space agency would not be able to protect the confidential details it was collecting.

The scientists took their case all the way to the Supreme Court only to lose last year.

This month, Dr. Nelson opened a letter from NASA telling him of a significant data breach that could potentially expose him to identity theft.

The very thing he and advocates worried about had occurred. A laptop used by an employee at NASA’s headquarters in Washington had been stolen from a car parked on the street on Halloween, the space agency said.

Although the laptop itself was password protected, unencrypted files on the laptop contained personal information on about 10,000 NASA employees — including details like their names, birth dates, Social Security numbers and in some cases, details related to background checks into employees’ personal lives.

Millions of Americans have received similar data breach notices from employers, government agencies, medical centers, banks and retailers. NASA in particular has been subject to “numerous cyberattacks” and computer thefts in recent years, according to a report from the Government Accountability Office, an agency that conducts research for Congress.

Even so, Dr. Nelson, who recently retired from the Jet Propulsion Laboratory, a research facility operated by the California Institute of Technology under a contract with NASA, stands out as a glaring example of security lapses involving personal data, privacy advocates say.

“To the extent that Robert Nelson looks like millions of other people working for firms employed by the federal government, this would seem to be a real problem,” said Marc Rotenberg, the executive director of the Electronic Privacy Information Center, an advocacy group which filed a friend-of-the-court brief for Dr. Nelson in the Supreme Court case.

In a 2009 report titled “NASA Needs to Remedy Vulnerabilities in Key Networks,” the Government Accountability Office noted that the agency had reported 1,120 security incidents in fiscal 2007 and 2008 alone.

It also singled out an incident in 2009 in which a NASA center reported the theft of a laptop containing about 3,000 unencrypted files about arms traffic regulations and wind tunnel tests for a supersonic jet.

“NASA had not installed full-disk encryption on its laptops at all three centers,” the report said. “As a result, sensitive data transmitted through the unclassified network or stored on laptop computers were at an increased risk of being compromised.” Other federal agencies have had similar problems. In 2006, for example, the Department of Veteran’s Affairs reported the theft of an employee laptop and hard drive that contained personal details on about 26.5 million veterans. Last year, the G.A.O. cited the Internal Revenue Service for weaknesses in data control that could “jeopardize the confidentiality, integrity, and availability of financial and sensitive taxpayer information.”

Also last year, the Securities and Exchange Commission warned its employees that their confidential financial information, like brokerage transactions, might have been compromised because an agency contractor had granted data access to a subcontractor without the S.E.C.’s authorization.

In a phone interview, Dr. Nelson, the astronomer, said he planned to hold a news conference on Wednesday morning in which he would ask members of Congress to investigate NASA’s data collection practices and the recent data breach.

Robert Jacobs, a NASA spokesman, said the agency’s data security policy already adequately protected employees and contractors because it required computers to be encrypted before employees took them off agency premises. “We are talking about a computer that should not have left the building in the first place,” Mr. Jacobs said. “The data would have been secure had the employee followed policy.”

The government argued in the case Dr. Nelson filed that a law called the Privacy Act, which governs data collection by federal agencies, provided the scientists with sufficient protection. The case reached the Supreme Court, which upheld government background checks for employees of contractors. The roots of Dr. Nelson’s case against NASA date back to 2004 when the Department of Homeland Security, under a directive signed by President George Bush, required federal agencies to adopt uniform identification credentials for all civil servants and contract employees. As part of the ID card standardization process, the department recommended agencies institute background checks.

Several years later, when NASA announced it intended to start doing background checks at the Jet Propulsion Laboratory, Dr. Nelson and other scientists there objected.

Those security checks could have included inquiries into medical treatment, counseling for drug use, or any “adverse” information about employees such as sexual activity, or participation in protests, said Dan Stormer, a lawyer representing Dr. Nelson.

But Dr. Nelson and other long-term employees of the lab challenged the legality of those checks, arguing that they violated their privacy rights. NASA, they said, had not established a legitimate need for such extensive investigations about low-risk employees like themselves who did not have security clearances or handle confidential information. Dr. Nelson, for example, specializes in solar system science — concerning, for example, Jupiter’s moon Io and Titan, a moon of Saturn — and publishes his work in scientific journals

“It was an invitation to an open-ended fishing expedition,” Dr. Nelson said of the background checks.

In friend of the court briefs for Dr. Nelson, privacy groups cited many data security problems at federal agencies, arguing that there was a risk that NASA was not equipped to protect the confidential details it was collecting about employees and contractors.

In 2008, the United States Court of Appeals for the Ninth Circuit in San Francisco temporarily halted the background checks, saying that the case had raised important questions about privacy rights. But last year, the Supreme Court upheld the background investigations of employees of government contractors.

Dr. Nelson said he retired from the Jet Propulsion Laboratory last June rather than submit to a background check. He now works as a senior scientist at the Planetary Science Institute of Tucson.

NASA has contracted with ID Experts, a data breach company, to help protect employees whose data was contained on the stolen laptop against identity theft. Mr. Jacobs, the NASA spokesman, said the agency has encrypted almost 80 percent of its laptops and plans to encrypt the rest by Dec. 21. He added that he too received a letter from NASA warning that his personal information might have been compromised by the laptop theft.

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Nurses Sue Douglas Kennedy for $200,000

Yana Paskova for The New York Times

Two nurses have accused Douglas Kennedy, a son of Robert F. Kennedy, of assault and battery, negligence and causing them emotional and physical distress after an episode involving his newborn son.

Two nurses in Westchester County have filed a $200,000 lawsuit against Douglas Kennedy, a son of Robert F. Kennedy, accusing him of assault and battery, negligence and causing them emotional and physical distress after an episode involving his newborn son.

The Journal News of Westchester reported that the lawsuit was filed on Tuesday, a week after a court in Mount Kisco, N.Y., acquitted Mr. Kennedy of child-endangerment and harassment charges.

The charges stemmed from Mr. Kennedy’s attempt in January to take his newborn son from a maternity ward.

The two nurses said Mr. Kennedy hurt them as they tried to prevent him from leaving with the newborn. Mr. Kennedy said he was just taking the baby outside for some fresh air.

In a statement, Mr. Kennedy vowed to fight the lawsuit and said it was an attempt to extort money from his family.

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Nurses Sue Douglas Kennedy for $200,000

Yana Paskova for The New York Times

Two nurses have accused Douglas Kennedy, a son of Robert F. Kennedy, of assault and battery, negligence and causing them emotional and physical distress after an episode involving his newborn son.

Two nurses in Westchester County have filed a $200,000 lawsuit against Douglas Kennedy, a son of Robert F. Kennedy, accusing him of assault and battery, negligence and causing them emotional and physical distress after an episode involving his newborn son.

The Journal News of Westchester reported that the lawsuit was filed on Tuesday, a week after a court in Mount Kisco, N.Y., acquitted Mr. Kennedy of child-endangerment and harassment charges.

The charges stemmed from Mr. Kennedy’s attempt in January to take his newborn son from a maternity ward.

The two nurses said Mr. Kennedy hurt them as they tried to prevent him from leaving with the newborn. Mr. Kennedy said he was just taking the baby outside for some fresh air.

In a statement, Mr. Kennedy vowed to fight the lawsuit and said it was an attempt to extort money from his family.

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Op-Ed Contributor: Break Up the Telecom Cartels

SINCE 1974, when the Justice Department sued to break up the Ma Bell phone monopoly, Americans have been told that competition in telecommunications would produce innovation, better service and lower prices.

What we’ve witnessed instead is low-quality service and prices that are higher than a truly competitive market would bring.

After a brief fling with competition, ownership has reconcentrated into a stodgy duopoly of Bell Twins — AT&T and Verizon. Now, thanks to new government rules, each in effect has become the leader of its own cartel.

The AT&T-DirectTV and Verizon-Bright House-Cox-Comcast-TimeWarner behemoths market what are known as “quad plays”: the phone companies sell mobile services jointly with the “triple play” of Internet, telephone and television connections, which are often provided by supposedly competing cable and satellite companies. And because AT&T’s and Verizon’s own land-based services operate mostly in discrete geographic markets, each cartel rules its domain as a near monopoly.

The result of having such sweeping control of the communications terrain, naturally, is that there is little incentive for either player to lower prices, make improvements to service or significantly invest in new technologies and infrastructure. And that, in turn, leaves American consumers with a major disadvantage compared with their counterparts in the rest of the world.

On average, for instance, a triple-play package that bundles Internet, telephone and television sells for $160 a month with taxes. In France the equivalent costs just $38. For that low price the French also get long distance to 70 foreign countries, not merely one; worldwide television, not just domestic; and an Internet that’s 20 times faster uploading data and 10 times faster downloading it.

America’s Internet started out as No. 1 in speed. It now ranks 26th, far behind the networks in Bulgaria, Ukraine and Lithuania. Americans pay the sixth highest median price in the modern world for Internet data — 16 times the rates paid by South Koreans, according to the Organization for Economic Cooperation and Development.

Just as serious is the problem of coverage: in France, South Korea and other modern countries a superfast Internet is or will soon be available everywhere. In America, AT&T’s fiber optic lines stop short of homes and small businesses, while Verizon plans to end its fiber-optic installation work once it reaches 18 million residences.

As of now huge parts of the United States will never get on the information superhighway but will rather slog along on the digital equivalent of a country road. This presents a genuine economic threat to America: the future industries and jobs that require a universal ultra-high-speed network, after all, will most likely be developed somewhere else.

But the problem is more immediate for consumers. That’s because both of these cartels are telling lawmakers that they need less regulation, not more. A lighter government hand, they say, will mean more competition and yield a better deal for consumers.

In practice, though, deregulation has meant new regulations — written by corporations and for corporations — that have often thwarted competition and run roughshod over the customer.

Few know, for example, that since 1913, Americans have had a legal right to telephone service at any address — or did until recently. Asserting that we now live in a world of competitive telecommunications, the Bell Twins have already managed to repeal this right in at least six states (Alabama, California, Florida, North Carolina, Texas and Wisconsin). And the cartels are apparently working vigorously to extend this repeal. Doubters have only to count the lobbyists hovering around state legislatures: in Kentucky, AT&T employs 36 of them.

The new regulations have the potential to leave some customers with only mobile telephone service, which does not work in many areas. Moreover, some proposed new rules, if adopted, may actually put people at risk: AT&T, for instance, has suggested shutting down its old copper wire system — the only telecommunications platform that worked in some areas after Hurricane Sandy because it relies on a separate, minimal supply of electricity.

The remedy for these anti-consumer practices is straightforward: bring back real competition to the telecom industry. The Federal Communications Commission, the Justice Department and lawmakers have long said this is their goal. But absent new rules that promote vigorous competition among telecom companies, it simply won’t happen.

Just as canals and railroads let America grow in the 19th century, and highways and airports did so in the 20th century, the information superhighway is vital for the nation’s economic growth in the 21st. The nation can’t afford to leave its future in the hands of the cartels.

David Cay Johnston, a visiting lecturer at Syracuse University’s College of Law, is author of “The Fine Print: How Big Companies Use ‘Plain English’ to Rob You Blind.”

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Bombings Are Said to Kill Dozens Near Syria’s Capital

Francisco Leong/Agence France-Presse — Getty Images

Rebels celebrated on top of a downed Syrian jet in Daret Azzeh, 20 miles west of Aleppo, on Wednesday.

DUBAI, United Arab Emirates — Syrian state media said on Wednesday that 34 people and possibly many more had died in twin car bombings in a suburb populated by minorities only a few miles from the center of Damascus, the capital, as the civil war swirls from north to south claiming ever higher casualties. One estimate by the government’s opponents put the death toll at 47.

There were also reports from witnesses in Turkey and antigovernment activists in Syria that for the second successive day insurgents had shot down a government aircraft in the north of the country, offering further evidence that the rebels are seeking a major shift by challenging the government’s dominance of the skies. It was not immediately clear how the aircraft, apparently a plane, had been brought down.

Video posted on the Internet by rebels showed wreckage with fires still burning around it. The aircraft appeared to show a tail assembly clearly visible jutting out of the debris. Such videos are difficult to verify, particularly in light of the restrictions facing reporters in Syria. However, the episode on Wednesday seemed to be confirmed by other witnesses.

“We watched a Syrian plane being shot down as it was flying low to drop bombs,” said Ugur Cuneydioglu, who said he observed the incident from a Turkish border village in southern Hatay Province. “It slowly went down in flames before it hit the ground. It was quite a scene,” Mr. Cuneydioglu said.

Video posted by insurgents on the Internet showed a man in aviator coveralls being carried away. It was not clear if the man was alive but the video said he had been treated in a makeshift hospital. A voice off-camera says, “This is the pilot who was shelling residents’ houses.”

The aircraft was said to have been brought down while it was attacking the town of Daret Azzeh, 20 miles west of Aleppo and close to the Turkish border. The town was the scene of a mass killing last June, when the government and the rebels blamed each other for the deaths and mutilation of 25 people. The video posted online said the plane had been brought down by “the free men of Daret Azzeh soldiers of God brigade.”

On Tuesday, Syrian rebels said they shot down a military helicopter with a surface-to-air missile outside Aleppo and they uploaded video that appeared to confirm that rebels have put their growing stock of heat-seeking missiles to effective use.

In recent months, rebels have used mainly machine guns to shoot down several Syrian Air Force helicopters and fixed-wing attack jets. In Tuesday’s case, the thick smoke trailing the projectile, combined with the elevation of the aircraft, strongly suggested that the helicopter was hit by a missile.

Rebels hailed the event as the culmination of their long pursuit of effective antiaircraft weapons, though it was not clear if the downing on Tuesday was an isolated tactical success or heralded a new phase in the war that would present a meaningful challenge to the Syrian government’s air supremacy. In Damascus, the official SANA news agency said the explosions in Jaramana outside the city at around 7 a.m. were the work of “terrorists,” the word used by the authorities to denote rebel forces seeking the overthrow of President Bashar al-Assad. Photographs on the SANA Web site showed wreckage and flames in what looked like a narrow alleyway with cars covered in chunks of debris from damaged buildings. The agency said the bombings were in the main square of Jaramana, which news reports said is largely populated by members of the Christian and Druse minorities. Residents said the neighborhood was home to many families who have fled other parts of Syria because of the conflict and to some Palestinian families. The blasts caused “huge material damage to the residential buildings and shops,” SANA said.

The photographs on the Web site showed shattered windows at the Abou Samra coffee house and gurneys laden with injured people clogging what seemed to be a hospital corridor.

SANA said two bombings in other neighborhoods caused minor damage. Activists reported that there were four explosions and said they were all “huge.”

Footage broadcast on Syria’s private Addounia channel and state television showed damage scarring gray six-story apartment houses above tangles of wrecked cars as ambulances arrived to transport the wounded and rescuers spraying rubble with fire hoses. The camera panned over bloodstained sidewalks.

The blasts seemed initially at least to shift the focus of the fighting from the north, where insurgents have claimed string of tactical breakthroughs in recent days, to areas ringing Damascus.

In the north in recent days, the insurgents also claimed to have seized air bases and a hydroelectric dam, apparently seeking both to expand their communications lines and to counter the government’s supremacy in the air.

The death toll from Wednesday’s bombings was not immediately confirmed. An activist group, the British-based Syrian Observatory for Human Rights, initially said that 29 people had died but revised the figure later to 47, of whom 38 had been identified. Of the 120 injured, the rebel group said, 23 people were in serious condition, meaning that the tally could climb higher.

The explosions reflected the dramatic shift since Syria’s uprising began in March 2011 as a peaceful protest centered on the southern town of Dara’a. It has since spread across the land in a full-blown civil war pitting government forces against a rebel army of Army defectors, disaffected civilians and what the authorities say are foreign jihadists.

Hala Droubi reported from Dubai, United Arab Emirates, and Alan Cowell from Paris. Sebnem Arsu contributed reporting from Istanbul, and Hania Mourtada from Beirut, Lebanon.

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DealBook: ConAgra Foods to Buy Ralcorp for $5 Billion

8:37 a.m. | Updated

After being rejected last year, ConAgra Foods agreed on Tuesday to buy Ralcorp Holdings for roughly $5 billion in cash, reviving an effort to form the largest producer of private label packaged food in North America.

Under the terms of the deal, Ralcorp shareholders would receive $90 a share in cash, 28 percent above Ralcorp’s closing price on Monday. Including debt, the transaction is valued at about $6.8 billion.

Together, the two would have $4.5 billion in annual sales of private label goods, made for bakeries, grocery chains, restaurants and other food service customers.

“Ralcorp is already the largest private label food company in the U.S. and is well positioned for future growth,” Gary M. Rodkin, chief executive of ConAgra Foods, said in a statement. “Adding Ralcorp provides us with a much larger presence in the attractive and growing private label segment.”

Once regarded as the stepchildren of the food aisles, private label products have become brands in their own right as grocery store retailers have used them to set themselves apart from competitors.

Over the years, retailers invested heavily in improving the quality of their food products as well as the packaging and merchandising. Now, they have become ubiquitous among convenience stores, club stores, big box retailers and specialty concepts like Whole Foods and Trader Joe’s.

When the economy was weaker, consumers snapped up such private label brands, although a new report out on Tuesday from the SymphonyIRI Group, a market research firm, suggests that the growth of private label brands might be slowing.

The study found that the private label unit share of the total consumer packaged goods market fell to 17.1 percent in the 52 weeks ended Sept. 9 from 17.3 percent in the period a year earlier, although the dollar value of those products continued to inch ahead.

“Over the past two years, the trend of buying more private label brands has been flattening out, with dollar sales ticking up more slowly and unit sales declining slightly,” said Susan H. Viamari, editor of SymphonyIRI’s Times and Trends reports. “Consumers are still frugal, but because national brands have stepped up their game, they’re gaining back some share they lost to private label.”

Still, retailers are continuing to make investments in developing their private label lines. That is part of the reason ConAgra pursued Ralcorp so intently.

“Private label brands really have become true brands,” Ms. Viamari said. “There was a time when they were knockoffs you would bury in the bottom of your cart, but now in many cases they are just as good or even better than national brands and represent a smart purchase.”

The deal on Tuesday is a surprising turn of play for ConAgra, which unsuccessfully bid $5.2 billion to buy Ralcorp last year in an attempt to bulk up its generic foods business, supplementing its existing brands like Egg Beaters and Chef Boyardee.

But Ralcorp instead chose to spin off its branded cereals division – including Honey Bunches of Oats, Post Raisin Bran and Grape-Nuts – into a new company, Post Holdings. That company’s shares have risen nearly 27 percent since they began trading in February.

Ralcorp also made a number of acquisitions to bolster its remaining businesses.

Talks between the two companies revived this fall, when ConAgra again reached out about a union of the two food companies.

ConAgra expects to pay for the deal with existing cash, bank facilities and new debt. It plans to issue up to $350 million in new shares to help maintain its existing investment-grade credit rating.

ConAgra was advised by Centerview Partners, Bank of America Merrill Lynch and the law firm Davis Polk & Wardwell. Ralcorp was advised by Barclays, Goldman Sachs and the law firm Wachtell, Lipton, Rosen & Katz.

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Imaging Shows Progressive Damage by Parkinson’s

For the first time, researchers at the Massachusetts Institute of Technology report, brain imaging has been able to show in living patients the progressive damage Parkinson’s disease causes to two small structures deep in the brain.

The new technique confirms some ideas about the overall progress of the disease in the brain. But the effects of Parkinson’s vary in patients, the researchers said, and in the future, the refinement in imaging may help doctors monitor how the disease is affecting different people and adjust treatment accordingly.

The outward symptoms and progress of Parkinson’s disease — tremors, stiffness, weakness — have been well known since James Parkinson first described them in 1817. But its progress in the brain has been harder to document.

Some of the structures affected by the disease have been buried too deep to see clearly even with advances in brain imaging. An important recent hypothesis about how the disease progresses was based on the examinations of brains of patients who had died.

Now, a group of scientists at M.I.T. and Massachusetts General Hospital report that they have worked out a way to combine four different sorts of M.R.I. to get clear pictures of damage to two brain structures in people living with Parkinson’s. In doing so, they have added support to one part of the recent hypothesis, which is that the disease first strikes an area involved in movement and later progresses to a higher part of the brain more involved in memory and attention.

Suzanne Corkin, a professor emerita of behavioral neuroscience at M.I.T. and the senior author on the paper published online Monday in The Archives of Neurology, said that this progression was part of the hypothesis put forward in 2003 by Heiko Braak, a German neuroscientist, based on autopsies.

But, she said, because of the limits of brain imaging, “nobody could test this in living patients.”

David A. Ziegler, who was at M.I.T. when the research was done, and is now a postdoctoral researcher at the University of California, San Francisco, said that the study, of 29 patients with Parkinson’s and 27 healthy patients of roughly the same age, showed that the peanut-sized substantia nigra lost volume first, and another structure called the basal forebrain, involved in memory and attention, was struck later.

Glenda Halliday, a neuroscientist at Neuroscience Research Australia and the University of New South Wales, who was not involved in the study, said the paper confirmed “the progression of degeneration in two important affected brain regions in people with Parkinson’s.”

Dr. Corkin, Dr. Ziegler and their colleagues developed a way to use four different varieties of M.R.I. — each using different settings on the same machine — to come up with four different images that could be used to form one image that showed structures deep in the brain like the substantia nigra, long known to be important in Parkinson’s.

The disease kills brain cells, shrinking the parts of the brain that it affects, and the comparative study showed that the reduction in size of the substantia nigra showed up in early stage Parkinson’s patients, compared with a healthy group.

The reduction in size in the basal forebrain, compared with the healthy group, did not show up in the patients in the early stage, but was clear in patients in the later stage.

“This is a project we’ve been working on in our lab for years,” she said. A next step, already in progress, is to correlate damage to specific brain structures with symptoms.

Parkinson’s, she said, is a disease that shows the same broad outlines of development in most patients, but with considerable variation. Dementia may arrive early or may not appear. The M.R.I. technique described in the paper, she said, might help tease out what is going on in the brain in subgroups of Parkinson’s patients that show different symptoms and could influence treatment.

One important difference between the two brain structures is that damage to the substantia nigra decreases production of the neurotransmitter dopamine, while a smaller basal forebrain would reduce the production of a different chemical, acetylcholine.

The research is just one step, Dr. Ziegler said. One of the “big outstanding questions,” he said, is whether all patients will eventually get dementia.

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