Latest HIT news, on the fly...


Monday, January 26, 2015

An Epic development

How about some Mayo with your Epic?
Mayo taps Epic for EHR, revenue cycle management
Healthcare Dive Mayo Clinic announced this week that it would be abandoning its three current EHR systems in favor of a new contract with EHR giant Epic, which will now be the healthcare icon's sole EHR provider and strategic partner, according to a Mayo press release.

The plan is to deploy a single, integrated Epic EHR and revenue cycle management system at Mayo's main campus. Jilted in the deal are GE and Cerner, who were the providers of Mayo's current systems...
That's truly a big deal, particularly given this Mayo news:
Precision Medicine: Mayo Clinic Expert Describes Next Steps to Help More Patients

Rochester, Minn. – “Precision medicine” is becoming a national catchphrase after President Obama highlighted it in his State of the Union address. But what exactly is it? Richard Weinshilboum, M.D., acting director of the Mayo Clinic Center for Individualized Medicine, describes this new, rapidly advancing frontier in medicine and outlines 10 changes that would speed development and help more patients benefit from a personalized approach to health care:

What is precision medicine? In precision medicine, also called individualized medicine or personalized medicine, physicians use knowledge about a person’s personal genetic makeup to help determine the best plan for disease prevention, diagnosis and treatment. The mapping of the human genome in 2003 by U.S. scientists jump-started medical genomics; the Human Genome Project was an immense international collaboration that took 13 years and cost $3.8 billion. The National Institutes of Health’s National Human Genome Research Institute, which coordinated the project, estimates economic growth from that project at $798 billion.

"We are now poised to apply genomic technologies developed with the findings of the Human Genome Project into everyday patient care,” Dr. Weinshilboum says.
“However, if the U.S. is to remain the world leader in health care innovation and delivery, we need another national genomics effort that will accelerate scientific discovery and clinical implementation while continuing to encourage the rapid technological innovations and entrepreneurialism that have gotten us to this point."

What would help the U.S. continue to lead in precision medicine? President Obama’s call for a national initiative to advance individualized medicine, including increased funding to the National Institutes of Health to support advances in precision medicine, is an important step, Dr. Weinshilboum says. Other moves that would help include:

  • Adding bioinformatics to medical school and graduate school requirements to give physicians and other health care providers the tools they need to use genomic material.
  • Updating and expanding government regulations to keep up with the growth of genomic technologies and potential treatments, including providing alternative tracks for the development and use of medications for small subsets of patients.
  • Revising insurance guidelines to support genomic-based therapies.
  • Standardizing biobank activities, using the same terms and templates so biobanks are more universally useful.
  • Creating annotated, safe data repositories where all institutions can pool data and benefit from shared data while protecting patient privacy.
  • Developing a next generation of electronic medical records that can securely store genomic data or easily interact with secure genomic data storage warehouses to facilitate incorporation of genomics into routine medical care.
  • Using genomics to identify drugs that could be used as specialized cancer treatments.
  • Improving incentives for researchers to collaborate and work in teams.
  • Creating a national clearinghouse to match patients with genomic clinical trials.
  • Bringing together federal and state regulators to develop a clear pathway toward the approval of next generation-based sequencing tests.
What are some precision medicine terms that people might start hearing more frequently from physicians, researchers and policymakers?
  • Whole exome sequencing, also known as exome capture: A laboratory process that determines, all at once, the entire unique sequence of a person’s exome. The exome consists of all of the protein coding genes in a person’s DNA. These genes, which contain the instructions for how a cell behaves, account for an estimated 1 to 2 percent of
  • Whole genome sequencing: A laboratory process that determines, all at once, the entire unique DNA sequence of a person’s genome. There about 6 billion “letters” in every human genome; everyone is unique.
  • Genetic variants: Each of us is about 99.9 percent the same, genetically speaking. Even so, that 0.1 percent adds up to about 3 million individual genomic variants that differ between any two people. A major challenge in individualized medicine is finding the handful of variants that may lie behind a person’s cancer, diabetes, or Alzheimer’s disease, for example.
  • Bioinformatics: A research field that focuses on the interpretation of genomic data and seeks to build sophisticated systems that help scientists and physicians quickly locate variants that play roles in diseases. This is a rapidly growing area: Scientists and physicians can now generate data much more quickly than they are able to interpret it.
  • Next Generation Sequencing: Also known as high-throughput sequencing, next generation sequencing describes several new DNA sequencing technologies that allow scientists and physicians to decode and catalog large numbers of genomic sequences in a rapid and cost-effective manner.
It has been asserted that only ~10% of "health" is attributable to clinical interventions, as I noted in my August 13th, 2014 post. e.g.,

So, if we can bring genetic assay-driven therapeutics into the applied clinical settings, the percentage will change dramatically (notwithstanding that vexing socioeconomc Upstream issues will remain). Assuming, of course, we'll have a sufficient number of genetically adroit clinical staff -- and that the Epic EHR platform will be up to the genomic data management and workflow tasks.

And, one should add, that such new "omics" interventions will be affordable.


From THCB:
Three Recommendations for President Obama’s Precision Medicine Initiative

...[A]nnouncing the initiative is one thing.  As with all policy discussions, the devil is in the details – and there are three details specifically that could make the difference between political rhetoric and a policy that truly improves the health of American citizens.
  1. Focus on the entire process of the disease – starting with prevention. Because most chronic diseases show few symptoms until the disease has significantly progressed, treatments for cancer and diabetes patients are primarily at the disease management phase. However, we are acutely aware that the best way to “cure” cancer or diabetes is prevention, and prevention requires better early diagnosis. Unfortunately, we still lack convenient and accurate ways to diagnose for various cancers and diabetes. Given the high costs of treating advanced-stage chronic diseases, precision diagnosis of risk factors or disease progression will materially lower the costs of health care...
  2. Strategically target diseases. Particularly in cancer and type-2 diabetes, two of the fastest growing disease segments in the United States, there is a significant opportunity for precision medicine to improve early diagnosis and treatment, and lower the costs of care. Remember, we tackled HIV and AIDS issues over the past thirty years with a precise target (HIV) and with research focused on quickly translating basic science to clinically effective and safe drugs. Because cancer and diabetes are systemic diseases, affecting multiple aspects of a human body, focusing on translational science based on specific types of cancer or specific aspects of diabetes may in fact accelerate not only the understanding of the diseases but also improve the treatment methods at each stage...
  3. Set standard definitions and metrics. One of the major challenges in migrating toward precision medicine is lack of a common clinical language and metrics that help us to refine our interpretations and focus our messages to physicians and patients. Because cancer and diabetes are still treated in the realm of intuitive medicine, different physicians can provide different opinions on these diseases. Although we need to appreciate individuals’ genetic and biological uniqueness in discussing chronic diseases, precision medicine cannot establish deep roots without more commonly accepted definitions and associated metrics...
Indeed. Recommendation #3 resonates with me in particular.

More to come...

Thursday, January 22, 2015

DeSalvo gets a salvo

The natives are restless.

January 21, 2015 

Karen B. DeSalvo, MD, MPH
National Coordinator for Health Information Technology
Office of the National Coordinator for
Health Information Technology
U.S. Department of Health and Human Services Hubert H. Humphrey Building, Suite 729D
200 Independence Avenue, SW
Washington, DC 20201 

Dear Dr. DeSalvo: 

The undersigned organizations are writing to elevate our concern about the current trajectory of the certification of electronic health records (EHRs). Among physicians there are documented challenges and growing frustration with the way EHRs are performing. Many physicians find these systems cumbersome, do not meet their workflow needs, decrease efficiency, and have limited, if any, interoperability. Most importantly, certified EHR technology (CEHRT) can present safety concerns for patients. We believe there is an urgent need to change the current certification program to better align end-to-end testing to focus on EHR usability, interoperability, and safety. We understand from discussions with the Office of the National Coordinator for Health Information Technology (ONC) that there is an interest in improving the current certification program. For the reasons outlined in detail below, we strongly recommend the following changes to EHR certification:
  1. Decouple EHR certification from the Meaningful Use program;
  2. Re-consider alternative software testing methods;
  3. Establish greater transparency and uniformity on UCD testing and process results;
  4. Incorporate exception handling into EHR certification;
  5. Develop C-CDA guidance and tests to support exchange;
  6. Seek further stakeholder feedback; and
  7. Increase education on EHR implementation.
Entire nine page letter here (pdf)

"Ensuring patient safety is a joint responsibility between the physician and technology vendor and requires appropriate safety measures at each stage of development and implementation. While training is a key factor, the safe use of any tool originates from its inherent design and the iterative testing processes used to identify issues and safety concerns. Ultimately, physicians must have confidence in the devices used in their practices to manage patient care. Developers must also have the resources and necessary time to focus on developing safe, functional, and useable systems.
Unfortunately, we believe the Meaningful Use (MU) certification requirements are contributing to EHR system problems, and we are worried about the downstream effects on patient safety..."
Opportunities for EHR Science?


This is sad.
Ebola Is Wiping Out the World’s Gorillas
In just four decades, Ebola has wiped out one third of the world’s chimp and gorilla populations. If it continues, the results will be devastating.

While coverage of the current Ebola epidemic in West Africa remains centered on the human populations in Guinea, Sierra Leone, and Liberia, wildlife experts’ concern is mounting over the virus’ favorite victims: great apes. 

Guinea, where the epidemic originated, has the largest population of chimpanzees in all of West Africa. Liberia is close behind. Central Africa is home to western lowland gorillas, the largest and most widespread of all four species. Due to forest density, the number of those infected is unknown. But with hundreds of thousands of ape casualties from Ebola, it’s doubtful they’ve escaped unscathed.

Animal activists are ramping up efforts to find an Ebola vaccine for great apes, but with inadequate international support for human research, their mission could be seen as competing with one to save humans. Experts from the Jane Goodall Institute of Canada insist such apprehension would be misplaced. Two streams of funding—one for humans, one for apes—can coexist in this epidemic, they assert, and must.

“The media was really focusing on human beings,” Sophie Muset, project manager for JGI, says. “But it has been traumatic to [the great ape] population for many years.”...

The dwindling population of both species, combined with outside poaching threats, means Ebola poses a very real threat to their existence. To evaluate the damage thus far, the Wild Chimpanzee Foundation is conducting population assessments in West Africa, with the goal of getting a rough estimate of how many have died. Given the combined damage that Ebola has inflicted on this population, the results are likely to be troubling.

In a way, great apes are Ebola’s perfect victims. Acutely tactile mammals, their dynamic social environments revolve around intimacy with each other. Touching hands, scratching backs, hugging, kissing, and tickling, they are near constantly intertwined—giving Ebola a free ride...
Wow. It ain't all about us.


From Healthcare IT News.
The experience of interoperability thus far
Support from EHR developers for clinically relevant workflow will be critical

John Halamka
...HL7 messaging addresses lab result and public health use cases very well. Lab results interfaces are straight forward, however there is still some need to reduce optionality in implementation guides so that the average lab interface costs $500 and not $5000. Public health transactions for immunizations, reportable lab, and syndromic surveillance are standardized from a content perspective but  there is still a need to specify a single transport mechanism for all public health agencies.

CCDA documents address transitions of care use cases reasonably well. CCDA is easier to work and parse than CCD/C32 because it has additional constraints and specifications, but there is still enough optionality that merging CCDA data into an EHR can be challenging. In addition, most EHRs generate a CCDA automatically and include all data that may possibly be relevant. In some cases, this leads to CCDAs that are rendered at 50+ pages. We need to reduce optionality so that CCDAs are easier to generate correctly and parse. EHR workflow needs to better support the creation of clinically relevant documents with narrative and data more specific to transitions.

Direct was a good first step for transport -- we needed to pick something. We could have required sFTP, REST, SOAP, SMTP/SMIME or even Morse Code as long as it was completely standardized. Unfortunately, we picked multiple options. Some EHRs use XDR (a SOAP transaction) and some use SMTP/SMIME. Whenever standards have an "OR", all vendors must implement an "AND". XDR must be translated into SMTP/SMIME and SMTP/SMIME must be translated into XDR.  The reality of Direct implementation has shown us that this optionality provides a lot of plumbing challenges. Certificate and trust issues are still an ongoing project. Getting data from medical devices via Direct is challenging since devices tend to use heterogeneous transmission protocols. Finally, SMTP/SMIME was never designed for large payloads of multiple files, so sending datasets greater than 10 megabytes can be a struggle. The use of XDM for zipping files before they are sent is overly complex to use as part of a transport protocol.

Although Direct works, it is often not well integrated into the EHR workflow.

FHIR, as discussed in multiple recent posts, can help address these challenges and leverage the lessons learned. The FHIR concept is that every EHR will provide a standardized interface for the query, retrieval, and submission of specific data elements and documents using a web-based RESTful transport mechanism and OAuth security. This use case can easily support unique modules or “bolt on” application functionality to EHRs. It significantly simplifies the interfacing challenge, works for large payloads, and minimizes optionality. There are no multiple transport options, no certificates to manage, and the query/retrieve processes can occur behind the scenes, enabling smoother workflow.

FHIR can even be helpful as a transition strategy while Direct is still used for pushing payloads between EHR. If FHIR/REST/OAuth replaced the XDR/XDM options of Direct, that provides a glide path to the eventual end to end replacement of Direct with FHIR

Once FHIR is available, EHR vendors should design a user experience that follows the IEEE definition of interoperability -- “the ability of a system or a product to work with other systems or products without special effort on the part of the customer."...
 My concerns regarding FHIR® persist. Beyond seamlessly integrating these "interfaced" data into "clinically relevant workflows" in ways that [1] don't put more sand in the workflow gears, and [2] don't leave the "imported" data reposed somewhere outside the recipents' RDBMS -- begging the question of easily assembling of the most recently updated complete legal patient record (vis the clinician acting upon the imported data elements) -- who is going to have to pay for all of this coding and QA validation work? Will FHIR ex/im functionality come to be required for ONC EHR certification, on the vendors' dime?

While I would say "yes," color me dubious.

What about HIPAA audit trail "chain of custody" data considerations?

I'm just asking. Below, from survey findings I recently saw in "API Integrity is a 'Must-Have' in the API Economy."


Cheryl and I attended the ASQ East Bay Section 0618 meeting Thursday evening. Very nice.
Please welcome our newest distinguished guest, Ms. Ritu Ganguly of ServiceMax Inc.  She will be presenting on the topic of "Testing in the Mobile World?"

Ms. Ritu Ganguly will lend her professional perspective on the emerging challenges of bringing quality to a mobile connected world.  Areas of discussion will include:
  • Advantages and Disadvantages for QA engineers
  • Basic similarities to the status quo, but note the differences...
  • What skills sets are needed by mobile testers?
  • How is Automation planning affected?
Ritu Ganguly is an experienced executive with over 18 years of experience in Quality, Technical Program management, Release management.  Her experience is in varied industries including ERP, CRM, HCM, Service and Healthcare software.  Her key strengths are building effective teams, fixing organizational issues, change management, quality process and software delivery.  Her professional journey includes mentoring and coaching quality engineers and managers for the last 10 years.  Most currently she was a part of Tech women mentorship program sponsored by the U.S State Department.  In addition, she was filmed by Stanford University for She++ videos to promote women in computing.

Ritu Ganguly has a Bachelor’s degree in Computer Science and a Master’s in Medical Informatics.  Born in India, she and has lived in Europe, Middle East and the U.S.  Her professional experience has been working for large enterprises such as PeopleSoft, Oracle, Salesforce and John Deere, as well as small startups such as Health Quality.

Currently she is a Vice President of Quality and Strategic Ops at ServiceMax Inc. ServiceMax is a Leader in Field Service Management software.

Specialties include:

  • Software development and quality management.
  • Quality of service (QOS) for Cloud Computing and Software as a Service  (SaaS)
  • Agile methodology and Scrum
  • Talent management, Team building, Career planning and development
  • Public Diplomacy, Global mentorship
  • Women empowerment
Excellent, thought-provoking presentation and discussion. Given the increasing penetration of mobile digital tech ("mHealth") in the healthcare space, issues pertaining to software (and hardware) QA will be ever more critical. I worry that "QA" in Mobile "apps" is to a distressing degree reactive, i.e., done on the backs of customers in the wake of uploaded bug/crash complaints ("Ignore" / "Send Report" / "Restart"). As a fellow attendee put it, "everything is now always in beta."

I am not at all mollified by the dismissive assertion you often hear from some vendors (particularly those claiming to be "doing Agile"): "We're ALL in QA."

Show me the comprehensive, executed test plans and the upshot documentation. Show me your QMS Manual.

More to come...

Wednesday, January 21, 2015

ICD-10: Be Very Afraid

Providers Fear ICD-10
By Katie Wike, Health IT Outcomes

Experts at AHIMA say ICD-10 deadline fears could be a contributing factor to physicians’ reluctance to perform testing.

Usually, providers cite financial reasons, time constraints, and limited staff when explaining their reluctance to adopt ICD-10. Now, an AHIMA report published by Perspectives in Health Information Management indicates that - put simply - fear is a factor as well.

The top concerns cited by the physicians participating in the AHIMA focus groups were
  • electronic health record software readiness
  • increase in documentation specificity and time
  • ability of healthcare professionals to learn a new language
  • inadequacy of current training methods and content
EHR Intelligence reports many of these physicians “expressed straight-up fear about how the new codes will impact their practices.”...
Will Congress kick this can down the road yet again? Rumors waft that such may be embedded in the next "SGR Doc Fix" legislation.

On the other side of the coin, ya gotta love this:
Why another ICD-10 delay could threaten national security
January 20, 2015 | By Susan D. Hall, Fierce Health IT

Though some medical groups keep pushing for yet another delay in ICD-10, Juliet Santos of consultancy Leidos Health, argues that another delay could be a threat to national security.

Santos, in an article at ICD-10 Monitor, says another delay could hobble the United States in the public surveillance of deadly health threats.

"Sicknesses and plagues have become weapons in modern-day warfare. Weaponized bioterrorism is rampant in other countries. ... We cannot prevent, monitor, track, manage, and control what we cannot see or find," Santos writes, mentioning ICD-9's non-specific and sometimes missing codes.

The new coding system will allow the U.S. to respond better to deadly outbreaks such as Ebola, she says. Although the specificity of ICD-10 has been the brunt of jokes--it includes nine different codes reflecting injury inflicted by a turkey--in ICD-9, Ebola is classified as 078.89, Other specified diseases due to viruses, a designation used for multiple viral diseases that have not been assigned a specific code. In ICD-10, it would have its own code--A98.4, Ebola.

"ICD-10 allows us to track and monitor patients with diseases similar to Ebola, because the codes are specific, the severity of illness is detailed, and we can determine illness rates as well as death rates," Santos writes...
Ahhh... yes, Ebola. Might the significantly increased granularity of ICD-10 vis a vis ICD-9 mitigate the coding problem I have called "Lossy Compression?"


These two animatronic co-presenters provide dramatic evidence of just how far life-like anthropic robotics have come.


 Wow. This one's a doozy.
...The job of prophets has always been to strip commoners of their ability to make independent decisions. Today’s prophets of disruptive innovation are showing us the road to becoming Roman patricians spending our entire lives sprawled on fainting couches while being fanned and fed gorgeous grapes by beautiful machines. The first thing we must do is to offload decision making to the precursor of the slave-savant machine of the future, so it can learn and practice the art and science of pleasuring us. Letting your GPS decide how to get from point A to point B is one example, and letting Google decide what you should read is another, although the latter may soon become obsolete, since enjoying grapes on your couch does not require any reading. Letting your “phone” decide when you should stand and when you should sit, when to eat and what to eat, and when you feel and how you feel is the next step in our evolution towards a perfect union between amino acids and silicon compounds.  

Perhaps nothing illustrates our glorious path to heaven on earth better than health care, and befittingly so, since health is life, hence health care is life care, is everything. The old definition of health care included mostly restorative medical activities to one’s health, but as the value of people keeps declining in an overpopulated global economy, and the costs of repairs are increasing, a more expansive, machine oriented, definition seems in order. People, you see, are essentially carbon-based machines, like say cars, the only analogy simpleminded voters seem to comprehend. To reduce your lifetime expenses on your car, and to enjoy a reliable vehicle for the duration, you need to have all the maintenance done on schedule (e.g. oil changes, tire rotation, filters, belts, etc.), drive carefully and obey the law, use the car sparingly, without too much starting and stopping, and you should wash and wax regularly, and generally keep it nice and clean inside and out.

You get the recommended preventive care for your model, all the screenings and tests, so any early signs of malfunction can be addressed, and you swallow all the recommended additives to make operations smooth and well lubricated, without undue stress to any of your parts, especially the feeble brain part. You refrain from reckless activities, and keep your mind and body clean on the inside and on the outside. The prophets, or futurists, as they prefer to be addressed today, are guiding us to all sorts of little silicon parts that we can incorporate in ourselves on the incremental road to transferring the limited intelligence functionality of biological creatures to superior artificial components. This simple process of artificial evolution towards a brighter future does not seem to come naturally to most people. These things never do. This is precisely why piety and obedience need to be enforced by cannons and laws, and here and there a few weaklings or outright skeptics must be made examples of what people should fear most...
From "Artificial Intelligence" by Margalit Gur-Arie

More to come...

Tuesday, January 20, 2015

Announcing the launch of Dr. Jerome Carter's Clinical Workflow Center

I have for some time closely followed the postings of Jerome Carter, MD at his blog EHR Science. Now comes his new initiative (I've known about it since last week, and have registered there, but he asked me to keep quiet about it until he went "live"). I know we're all now in the thrall of sexy cutting-edge healthcare space digitech, but it behooves us to not lose sight of some critical fundamentals. HIT devices and software apps are just tools. They still have to be effectively embedded in the workflows. Yeah, "disruption" is now a way cool term among the digerati and econ theorists, but actual disruption of clinical workflows makes those in the trenches crazy --  and risks harming or killing patients.

Clinical Workflow Center is a site dedicated to everything clinical workflow. It was created with the following goals in mind: 1) teaching clinical workflow analysis methods and 2) demonstrating the mathematical properties of clinical workflows and how those properties can be used to solve real-world problems. Since I consider workflow analysis to be a fundamental informatics skill, there are tutorials covering important workflow concepts and analysis techniques.  A Q&A forum is provided to for those who wish to share and ask questions. Resource pages offer a link to a wide varierty of useful materials.  Clinical Workflow Center is a companion site to EHR Science.

Why create a site decidated to clinical workflow topics?
Workflow disruptions are increasingly being recognized as workarounds, usability issues, safety concerns, and CDS problems. The first step to solving any problem is recognizing that it exists. In the case of HIT, this means acknowledging that clinical care consists of a series of specialized workflows. Clinical care consists of directed sequences of tasks that use, generate, or share information and that involve one or more individuals or machines. If the task sequence is wrong, the information incorrect or unavailable, or the wrong people, software or equipment involved, problems occur.

EHR system-clinical work impedanceThe automation of clinical care with current EHR systems has resulted in numerous complaints from clinical professionals who are fed up and discouraged by systems that make their jobs harder to do. The number of workflow disruptions that occur as a result of EHR use should surprise no one. Disruptions were to be expected because EHR systems are archival systems that do not contain models of clinical work. Making matters worse is the fact that EHR systems have their own internal workflows. Consequently, a good portion of EHR training is spent helping EHR users learn to adapt their workflows to those of the software. Thus, training times are one hint of impending EHR system-clinical work impedance and attendant clinician misery.

The problem with current clinical workflow approachesBeyond training, entire organizations have to adapt their processes to match the hard-coded workflows of EHR systems. Recent demands for improved system usability indicate the amount of misery that EHR-clinical work impedance has caused. However, the solutions proposed do not seem to grasp just how fundamentally important workflow issues are.

Understanding exactly how clinical work is disrupted or enhanced, whether using software or not, requires the ability to precisely model clinical work.   And here is where the first major problem arises. Most modeling approaches used in clinical settings are based on flowcharts and swim-lane diagrams. Neither of these tools offers a means to capture all information movements, resource interactions and complex task sequences in one unified model. Unfortunately, attempts to improve the fidelity of workflow models often involve adding UML (e.g. state, activity) and other diagrams to the mix such as data flow diagrams. The key to better modeling is not more diagrams, but rather a single framework that allows for representation of all workflow concepts.

Obviously, detail is required to determine how the information needs of a nurse doing a patient intake are best mapped to his/her physical actions. This leads to the second problem: current workflow modeling efforts are usually insufficiently detailed for the processes they represent. This lack of detail is evident in workflow modeling training materials (see Clinical Workflow Analysis: The Value of Task-Level Detail ).

Workflow modelers seeking to add detail to their diagrams have another problem: there are no formal standards for encoding clinical work such as task names, step increments, information requirements, or notation symbols. Lacking such standards, models of the same workflows from different modelers will likely differ significantly. Such variation impedes learning and the progress of clinical informatics as it concerns understanding the interplay of clinical work and clinical care software (see Modeling Clinical Workflows and Processes). Fortunately, there has been a significant amount of workflow research in the last 20 years, and all of it can be applied to health care.

Workflow research outside of clinical careAutomation of business processes has been a major focus of workflow research in the computer science, engineering and business communities. While automating processes is a worthwhile goal, workflow research — especially that focused on creating process models — can also be used to study clinical care activities at the lowest levels and build abstract models for analysis. Automating a process before fully understanding it can be disastrous. If one is losing money because of bad billing processes, automating those processes “as is” will result in bigger losses. Thus, some degree of analysis and modeling are essential before any attempts at automation. Clinical organizations that have been successful in implementing clinical software get this point.

Workflow patterns have the ability to express every major aspect of clinical workflows. Yes, they must be adapted to clinical use, but the basic concepts stand. Even better, workflow patterns and Petri nets are based in mathematics, which assures that precise meanings and notations are possible. Again, some changes and adjustments are required for clinical care, but the required changes are not rocket science. Aside from workflow patterns and Petri nets, I will go out on a limb (not far) and state that every clinical workflow (e.g., task sequence, information movements, and resource interactions) can be represented by a combination of common mathematical objects–logic, sets, functions/relations, and graphs. It is time to take the rich legacy of workflow research from computer science, engineering and business and apply it to understanding how clinical care happens.

Workflow disruptions by any other name…When caring for a patient, information is important. When and/or where in a care process information is required, collected, saved or shared are not simply usability issues, or safety problems, or human factors concerns, they are basic workflow issues as well. Addressing information needs requires close attention to workflow tasks and how they are sequenced. Who or what will participate in or complete a task are likewise workflow issues.

Given the importance of workflow to clinical care, the ability to expertly conduct workflow analyses should be right up there with being able to normalize a database or understand basic programming concepts as a training curriculum objective. In light of the fact that so many aspects of software selection/implementation, safety, usability, and CDS are workflow-based, clinical informaticists should be experts in analyzing and modeling clinical processes.
I hope this effort gets significant traction. Clinical workflows are irreducibly complex, high cognitive burden processes, and, given that digital health IT is not going away, the topic needs more effective and more widely visible analytical scrutiny and collaboration in pursuit of material improvement.

to wit

We’re all dressed up with nowhere to go. We’ve got our labs, real-time wireless sensor data, genomic sequence information, and images. Our ability to generate big medical data about an individual has far outstripped any semblance of managing it, and we can’t even build the full GIS yet. There is not a single electronic medical record (EMR ) system today that is set up to bring all this data together in a meaningful way— not just to aggregate it, but to provide the full analysis of all one’s medical information. It’s like we invented the printing press but haven’t figured out the card catalog. This isn’t necessarily because no one has tried; there are plenty of obstacles, but also, in spite of them, some early signs of progress. We’re talking about access, not ownership, a baby step in the right direction... [pg 125]
Doctors and the Medical Community 
With disinclination to change embedded in the medical community, reflected by the average time gap of seventeen years from innovation to adoption in medical practice, we need a cultural change. While digital native doctors just coming out of medical school or finishing residency training understand the sea change that is unfolding, there are millions of practicing physicians around the world who do not. We don’t have time to wait for a new generation of doctors and health care professionals to take hold. Cultural change is exceedingly difficult, but given the other forces in the iMedicine galaxy, especially the health care economic crisis that has engendered desperation, it may be possible to accomplish. An aggressive commitment to the education and training of practicing physicians to foster their use of the new tools would not only empower their patients, but also themselves. Eliminating the enormous burden of electronic charting or use of scribes by an all-out effort for natural language processing of voice during a visit would indeed be liberating... [pg 289]

Topol, Eric (2015-01-06). The Patient Will See You Now: The Future of Medicine is in Your Hands Basic Books. Kindle Edition.
Fabulous book.

Dr. Carter certainly has the Cred in this area.
Jerome H. Carter, MD, FACP, FHIMSS  is a board-certified internist who has been active in the field of medical informatics since completing a fellowship in 1987. He is also Adjunct Clinical Associate Professor of Medical Education at Morehouse School of Medicine (MSM) in Atlanta, GA.

Dr. Carter was previously Assistant Professor of Medicine at the University of Alabama-Birmingham (UAB) where he was Director of Informatics for the 1917  Patient Care and Research Clinic. At the 1917 Clinic, he led a five-year effort to design, build, and implement an electronic health record system optimized for patient care and outcomes research. During that time, he also directed the selection and implementation of a dental practice management and electronic record system.

While at UAB, Dr. Carter was also a member of the graduate faculty in the Master of Health Informatics Program. For six years, he was course director of “Clinical Documentation and Information Systems in Support of Patient Care”, which addressed issues related to the implementation and use of clinical information systems. A major emphasis of the course was the analysis of information system implementations in a variety of settings. Over the period 1995 to  2001, more than 40 health care entities from small practices to hospitals were studied in an effort to understand what makes for successful implementations.

Dr. Carter is the editor of Electronic Health Records, Second Edition (April 2008), published by the American College of Physicians. He served as a member of the American College of Physicians' Subcommittee on Medical Informatics from 1993-2001 (Chair, 1997-2001). From 2003 through 2007, he served on the Board of Scientific Counselors, Lister Hill Center, of the National Library of Medicine. Dr. Carter was co-chair of the HIMSS Electronic Health Records Adoption Task Force from  2007  until 2009.

Dr. Carter is a member of the following organizations: American College of Physicians, Association for Computing Machinery, American Medical Informatics Association, Healthcare Information and Management Systems Society,  IEEE - Computer Society, and CompTIA.
From EHR Science
One thing that seems important to address from the outset is the definition of clinical workflow. There are many definitions of workflow concepts available. I favor those provided by way of workflow patterns. Here are the definitions provided by Russell, et al. (1).

A workflow or workflow model is a description of a business process in sufficient detail that it is able to be directly executed by a workflow management system. A workflow model is composed of a number of tasks which are connected in the form of a directed graph.
These definitions are focused on automation and not clinical work. I would like to adapt these definitions, and workflow patterns in general, for clinical work. Should these efforts be successful, the result would be a set of shared conventions (e.g., definitions, analysis methods, terminology, modeling representations) for clinical workflow analyses and models that are easily shared and understood across clinical sites and application domains—usability, CDS, patient safety, software design. And, in keeping with the definitions provided by Russell et al., these models would also be executable by workflow technology. Flowcharts and swim lanes are great for discussions, but they are not executable.
Here are the definitions that will be used on CWC.

  • Clinical Work – Activities performed to assess, change or maintain the health of a patient.
  • Clinical Process – A specific clinical work activity undertaken by one or more clinical professionals with a specific start point, end point, and an expected outcome.
  • Clinical Workflow – The directed series of steps comprising a clinical process that 1) are performed by people/equipment/computers and 2) consume, transform and/or produce information. (Note that patient outcomes count as information.)
  • Clinical Workflow Model – A human-readable visual representation of a clinical workflow that can be executed by workflow technology.
One of my old REC "directed graphs." Fairly high level, marginally adequate. Conducted a pre-EHR implementation clipboard/walk-thru interview of the doc and his staff. Tried to compactly show what would go away and what would change via the conversion from paper to electronic.

The problem with these is that they are simply "logic flows" (laid out to fit pagination constraints to boot) and do not depict the time consumed, or the hand-offs, explicitly (my crude proxy for the hand-offs was color-coding).

Hand-offs ("swimlanes") and time consumption might look like this:

Click to enlarge

See my prior post Clinical workflow: "YAWL," y'all? for more of my brief workflow concept illustrations.


From the President's 2015 SOTU transcript: 
"21st century businesses will rely on American science, technology, research and development. I want the country that eliminated polio and mapped the human genome to lead a new era of medicine — one that delivers the right treatment at the right time. In some patients with cystic fibrosis, this approach has reversed a disease once thought unstoppable. Tonight, I’m launching a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes — and to give all of us access to the personalized information we need to keep ourselves and our families healthier.

I intend to protect a free and open internet, extend its reach to every classroom, and every community, and help folks build the fastest networks, so that the next generation of digital innovators and entrepreneurs have the platform to keep reshaping our world."
As noted on, 
POTUS Just Announced a New Precision Medicine Initiative
Precision medicine is an emerging approach to treating illnesses that takes into account a patient’s individual genetic make-up as well as molecular subtypes of diseases to improve the chances of successful treatment.
We'll have to see what comprises the details.

More to come...

Sunday, January 18, 2015

Let a thousand banalities bloom

With respect to
"Leveraging Holistic, Transformational, Innovative, Disruptive, Patient-Centric and Empowering Digital Health Space Ecosystem Paradigm-Shifting Curations, including Seamless Agile Scrum Lean Six Sigma DMIAC Gemba Workflows and Big Omics Data Hadoop-coded Post-RDBMS, Post-SQL HL7® FHIR® API Synergistic Interoperability Solutions encompassing The Upstream, inclusive of All Stakeholders."
Crash Davis, - Bull Durham

I first came to health care ("healthcare"?) analytics in 1993 in the wake of years of writing 3GL/4GL "apps" code (pdf) in an environmental radioanalytics lab in Oak Ridge and then writing technical marketing literature (pdf) for an industrial diagnostics company in West Knoxville (I loved that gig, gave it up in deference to my sweetie).

After moving from Tennessee in 1992 in the wake of my wife's promotion and transfer to Las Vegas (Nevada Test Site radiation cleanup project QA Manager), I took up my first of three tenures with what was at the time known as the "Nevada Peer Review," a Medicare "PRO" (Peer Review Organization).

CMS, then known as "HCFA" -- the Health Care Financing Administration -- set about to "re-brand" the PROs into "QIOs" (Quality Improvement Organizations). We would henceforth progressively set out to "transform the healthcare system." No more stodgy post-hoc UTIL and "appropriateness of care" manual chart-abstration "QA" case reviews done by veteran, flinty-eyed, chain-smoking, shuffling floor-burnout-case RNs who could read adroitly across the dx and px codes and pt demographic data in the UB-82 output claims files (often with a cigarette in hand) and quickly paint you a vivid picture of the benes' clinical travails and their respective prognoses.

One of my first assignments (prior to our "QI Transformation") involved the empirical study of Medicare bene 5- and 30-day re-admissions in Nevada acute care facilities (pdf).

Another quick story from those days, as I originally posted on another of my blogs some years ago:
During my first tenure (early 1990's) serving as an analyst for the Nevada/Utah Medicare Peer Review Agency (they're now called "QIO's" - Quality Improvement Organizations), in addition to our core Medicare oversight work, we had a number of small sidebar contracts, one of which involved ongoing analytical assessments of the Clark County Nevada self-funded employee health plan. One morning I accompanied my Sup, our Senior Analyst Dr. Moore, to a regular meeting of the plan's Executive Committee, wherein we would report on our latest plan utilization/outcomes evaluation.

A portion of the morning -- perhaps a half-hour, IIRC -- was always devoted to hearing claims denials appeals brought by Clark County employees. This day, two appeals were heard: one regarding an outpatient medical claim, the other concerning a dental encounter. The total sum at issue was about $350. Both appeals were denied, thereby "saving" the plan this nominal amount.

Bored by this administrative tedium, as I sat at the conference table, I did a quick, rough estimate back-of-the-envelope calculation. About a dozen executive/professional people consumed a half hour adjudicating these disputes, or, equivalently, 6 FTE hours. Assume a plausible blended G&A-multiplied cost estimate of the total compensation time for all these folks, plus all of the clerical/administrative time consumed in the processing (and subsequently denying) of these minor claims from the moment of their filing to this very hour.

Clark County easily spent well in excess of an additional $1,000 to "save" $350 at the expense of these two hapless employees, by my reckoning.

Similar scenarios -- public and private -- surely play out every day within our "health care system." Clark County would have been way ahead to have simply vetted the initial claims for fraud and then paid them! (This is one observation implicitly at the heart of the "Universal Coverage / Single Payer" model.)

But, as my Senior Medical Director was fond of pointing out, "every misspent dollar in our health care system goes into someone's paycheck."
Fast forward 20-some years. I'm sure financially enervating claims processing hassles continue unabated, and CMS continues to "study" Readmits. Maybe this time we'll make significant "absolute rate reduction" headway on readmits. We have better data now.

Given that my wife and I were (and continue to be) huge Deming fans, I was ecstatic about the new QIO direction. We renamed ourselves "HealthInsight," and went all-in Kumbaya in an (only partially successful) effort to put our vestigial Utah/Nevada bi-state shotgun-marriage antipathies behind us (UPRO had acquired NPRO after the latter had lost its Medicare contract prior to my coming on board; the respective "cultures" could not have been more different -- straight-laced, Rated-G, cookies-and-milk LDS Utah vs neighboring Cutty, Camels, and Card-Counting Nevada).

We studied under the acclaimed Dr. Brent James at IHC to get up to speed on the latest in CQI Progressivism. I still have my 2" thick training manual. It's as relevant today as it was in 1994. Brent rocks.

Two subsequent episodic tenures with HealthInsight later (the latter concluding with my 2013 REC "retirement"), I'm still largely awaiting (yes, with some exceptions) all of these broadly systemic, paradigm-shifting transformations. Mostly what we see are hard-won incremental improvements, prevailing marginally over incumbent intransigence.

We do, however, seem to naturally excel at cherubic marketing cliches. I had my fill of them this week.

Oh, and, one I failed to mention: "The Uber of healthcare!"

Right. To go all hip-hop lyrical for a sec, healthcare needs an Uber like it needs another Gruber.


Couple of interesting comments over at THCB.

Indeed. I recall Dr. James cautioning us early on during our IHC training "don't think we're going to QI our way out of the larger societal problem."


Can Lean QI liberate health care systems from "the inefficient tyranny of annual budgeting"? From The Thedacare Center for Healthcare Value:

I've followed and repeatedly cited Dr. Toussaint's work across the life of this blog.

More to come...

Thursday, January 15, 2015

Health 2.0 WinterTech 2015 in San Francisco

A long, glorious day, filled with powerful presentations and panel discussions. I left the house at 5:45, hit the BART at 6:17, read a good bit of Dr. Topols' new book "The Patient Will See You Now" on the way in from the Pittsburg/Bay Point station. Short walk from the Embarcadero station to 465 California Street and the interesting Julia Morgan Ballroom.

Below, Matthew Holt and I agree on this issue.



The subtitle of Dr. Topol's book could serve as a concise summation of the body of WinterTech topics I just saw: "The Future of Medicine is in Your Hands."

...the essence of a new era of medicine. It is powered by unplugged digitization, with the smartphone as the hub. We have seen this model already adopted in retail, travel, dining, entertainment, banking , and virtually every other industry. It’s all on demand and instantaneously executed. This has moved far beyond just having a prosthetic brain for a search or a built-in navigation GPS. In almost any endeavor , getting things done in a flash has become the norm, except in medicine. But that is now inevitable.
Getting first-rate health care will always be quite different from ordering something from Amazon. We’re talking about the most precious part of life— one’s health— not buying a book. But the common thread is the power of information and individualization. We are embarking on a time when each individual will have all their own medical data and the computing power to process it in the context of their own world. There will be comprehensive medical information about a person that is eminently accessible, analyzable, and transferable. This will set up a tectonic (or “tech-tonic”) power shift, putting the individual at center stage. No longer will MD stand for medical deity. What have been dubbed the six most powerful words of the English language—“ The doctor will see you now”—will no longer be true. Indeed you will still be seeing doctors, but the relationship will be radically altered. 

The doctor will see you now via your smartphone screen without an hour of waiting, at any time, day or night...

It might not be your primary care doctor, but it will be likely be a reputable physician who is conducting part of his or her practice through secure video consults. And those consults will involve doing parts of the standard physical examination remotely. More importantly, they will incorporate sharing your data— the full gamut from sensors, images, labs, and genomic sequence, well beyond an electronic medical record. We’re talking about lots of terabytes of data about you, which will someday accumulate, from the womb to tomb, in your personal cloud, stored and ready for ferreting out the signals from the noise, even to prevent an illness before it happens. 

The Power Shift 
 More is at play than just your “little” big data. Let’s drill down on the term democratization, meaning “to make something available to all people.” Until now, the flow of medical data has been to the doctor. If a patient was fortunate enough, their data, such as results of lab tests or scans, might arrive in the mail. More likely, but still rare, would be for the bottom line (like “everything is normal”) to be relayed via a phone call, often via a nurse or office assistant. The really lucky patient (with a less than 1 out of 10 chance in the United States) might even get an e-mail with attachments that include all their data.

But the world is changing now. Patients are generating their own data on their own devices. Already any individual can take unlimited blood pressures or blood glucose measurements, or even do an electrocardiogram (ECG) via their smartphone. The data are immediately analyzed, graphed, displayed on the screen, updated with new measurements, stored and, at the discretion of the individual, shared...
Topol, Eric (2015-01-06). The Patient Will See You Now: The Future of Medicine is in Your Hands (pp. 4-6). Basic Books. Kindle Edition. 
OK, well, let's start with an early panel example. Dr. Lena Cheng, and Doctor on Demand.

Lena is an internal medicine-trained physician and digital health expert with over fifteen years experience in clinical medicine and healthcare strategy. She brings her passion to Health 2.0 as she showcases the speed, efficacy, and care delivered via Doctor on Demand.
The Better Way to Feel Better
See a doctor, psychologist or other provider – from the comfort of home, or on the go
Doctor On Demand Video Visits allow our physicians, psychologists and lactation consultants to provide focused care – without you having to leave your home. With Video, they can Look, Listen, and Engage with you to diagnose your issues and provide an effective treatment plan.
Well, we'll see. I'm fixin' to try this service. I am effectively without a Primary these days. After I retired from the REC, sold the house in Vegas in September 2013, and moved over to Contra Costa County, I ended up in the Muir system. My new doc there is a nice young Internal Med D.O. whose answer to everything is to refer me to a specialist -- even to get a dad-gumbed scrip refilled! e.g., from one of my TCHB comments:

It's Tramadol 50 mg. I have some bulging disks and pinched nerves ("cervical and lumbar spondylosis with myelopathy"), in part the upshot of too many years of getting the crap knocked out of me while pursuing my absurd decades-long full-court Hoop Dreams, (I have the attestational eyebrow suture scars, and torn meniscal and MCL vestiges), followed by too many recent years of too much sitting, reading, and blogging for hours and days on end.

I usually took one Tramadol a day, in the early morning upon arising (even though the scrip said 'one every 4-6 hours as needed'). On bad days, I'd drop a 2nd one mid-day. They helped. Materially.

Given that DEA recently "rescheduled" Tramadol, I can't help but wonder whether my young doc wants to keep his fingerprints off the Rx. I'd given him my entire longitudinal Hx from my Vegas Primary, dumped from the EHR. I fail to see the point of doing an expensive encounter with yet another physician -- one who doesn't know me, and who will have to redundantly (and expensively) read the chart, listen to (or blow off) my CC Subjective, and either bless or deny the simple Rx request.

I note on the EOB that Muir charged me and my BC/BS $436 for each primary care visit (Cheryl and I are now on high-deductible HSA). I dutifully underwent the PT regimen he wrote me for (it helped a bit). I dutifully do my exercises. My cut of the nearly $3k for that was just shy of $1,200. My paid OOP for 2014 came to about $3,600 (welcome to the ACA). For a lot of people, that might be extremely painful in its own right.

Knowing that I would have another annual visit coming up, I went into Muir's portal to schedule it and request a lab draw order (blood and UA panels) to avoid another $436 charge for a pleasant (MU-compliant) 30 minute 99213 chat just to essentially pick up a lab slip and incur yet another charge for the f/up.

He refused. Had some Muir employee call me the following week with the news. Didn't respond (for the record?) to my portal email.

I told the caller to just cancel my appointment request.

Maybe Doctor on Demand won't be able to help me. The cost of finding out will be nil. I'll pay by credit card.

Had I the right iPhone apps (suitably QC vetted, of course, for clinical accuracy and precision), I'd prick my finger, pee in a cup, and run the specimens for my own labwork. Maybe most patients aren't competent to evaluate them. That is not the case with me. I know what to look for, what safely seems negligible, and what needs MD attention.

Dr. Topol:
Patients are intrinsically remarkably smart—they know their own bodies and the context of their lives—and no one has a bigger interest in their own health. That doesn’t mean, however, that they do all (or any of) the right things to stay healthy, but when things do go wrong, they are pretty darn good at detecting a problem. But we’ve learned that, in general, doctors don’t like smart patients. In fact, a recent study of physician attitudes found that: “patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions.” 
Those attitudes won’t be enough to hold back a whole new generation of even smarter patients and hopefully more supportive and smarter doctors. Indeed, they’re already all around us. [ibid, pg 8]
Coming up:, Hi.Q, Food Scores, and more. Oh, and, I gotta have one of these:

Dr. Tejash Shah of Samsung. Presenting wristband telemetry.


I would think so. And, audit-proof 45.CFR.164.3, .4, and .5 compliance are no cakewalk. On the ePHI security side, things begin with 45 CFR 164.308 - Administrative safeguards ("Core 15" in MU-speak). Which commits you to the gamut of 164.3, including physical and technical safeguards. 164.4 goes to breach notification, and 164.5 goes to privacy. -- which is complicated by the fact that, unlike prevailing "federal primacy" in general, HIPAA regs are subordinate to state privacy laws and regulations where the latter are deemed more strict. All of HIPAA Security and Privacy now apply equally to Covered Entity Business Associates.



Pretty good summary of EWG's Food Scores app.


I've surfed around for a bit. Most of the docs that pop up in my area are affiliated with Muir. Our service area is increasingly dominated by Kaiser, Muir, and Sutter. Kaiser is a non-starter for me, given my insurance, notwithstanding that it would be my preference clinically. I may have to expand my search geography. But, independents are a vanishing breed generally here in the Bay Area.
Regarding my frustrating $436 Muir visits. A long-standing joke in Las Vegas: "Q: Where do you go when you need medical attention in Las Vegas? A: The airport." I just checked my Expedia account. I can get round-trip airfare, a decent hotel (3 nights), and a rental car for $280 inclusive. Add to that a bit of gas, and my Senior discount BART Clipper card fare to SFO and back home. ~$300 total. I can go see my old pals at The Palms, hear some great music, shoot some new shots of them, and go see my old Primary, Dr. Gong for a checkup and get my friggin' scrip renewed.
Vegas as a "Medical Tourism" destination? LOL. Who'da thunk?


My New Yorker just arrived in the mail. Powerful, poignant cover art.



"Health Literacy" app. Very cool, a nuanced, detailed (but entertaining) approach. Presented by co-founder and CEO Munjal Shah.

Impressive presentation. One of my favs of the day. Definitely getting this app.
"Hi.Q is an innovative self-care example of how we should be approaching health today. Regardless of any disease or condition a person might have, knowledge is extremely influential in preventing future health risks and hospitalizations."
- Dr. Isaac Kohane, MD
Their website is beautiful, surf it at length.


When you hear the word “empowerment,” it’s code for “You’re on your own, pal.”
Health care leaders are starting to recognize that consumers are becoming a major decision-making force. Let’s be clear at the outset: The rise of the consumer is not the panacea that will solve all our problems. It is a reality that hospitals and health systems must respond to. For the foreseeable future, consumers will pay more for health care and be more involved in picking plans, providers and individual treatment options. This development means significant financial consequences for consumers (unlike almost any other developed country)...
Click the title. A long post worthy of your time and attention amid all this fawning celebration of ostensibly salvational technology and innovation.
"As more of the market moves to exchanges, as high-deductible health plans and narrow networks proliferate, and as managed care in public programs such as Medicare and Medicaid become the norm, so consumers will be asked to make more decisions, increasingly with their own money."
Yeah. And to their credit, a number of the panelists today emphasized the ultimate question of value (vs "valuation") -- will people actually pay for this stuff?


A day-long, intense parade of smart, eloquent, committed people spanning the breadth of the space, from tech to policy to investment.

I'll try to caption the above with names where I can. My apologies to those whom I may have missed. I was busy trying to make lemonade of the relatively uneven, inadequate lighting (I counted 7 front/side parcans, no backlighting). Yeah, I'm spoiled.

BTW- I accorded Vik Khanna a permanent link for his new book in the upper right links column. I'd reviewed it in a prior post. "Empowerment," "personal fitness/wellness responsibility," "consumer education," etc. The topics certainly fit with many of the themes expressed at WinterTech 2015.

Done for now. I'm baked. Gotta go practice my guitar. Thanks to Health 2.0 for the press pass. Your conferences are always top-shelf (with the exceptions of the skim and soy milk).


I'd intended to blab on a bit tying together the thematic elements I took away from Thursday's conference, alluding to some of the topics I'd not addressed in the foregoing, e.g., mental health issues, Big Box health retailing, "omics" developments, the "fashion" and "gamification" nudging aspects of health/fitness wearables, "Big Data" implications, etc. "Social Determinants of Health"? The implications of all things "Upstream" (including the socioeconomic)?

But, my new Harper's arrived today. Perhaps some thoughts from it will serve the larger picture just as well.

From the (paywalled) issue:
The Melancholy of Anatomy
By Wendell Berry

We need to acknowledge the formlessness inherent in the analytic science that divides creatures into organs, cells, and ever smaller parts or particles according to its technological capacities.

I recognize the possibility and existence of this knowledge, even its usefulness, but I also recognize the narrowness of its usefulness and the damage it does. I can see that in a sense it is true, but also that its truth is small and far from complete.

In and by all my thoughts and acts, I am opposed to any claim that such knowledge is adequate to the sustenance of human life or the health of the ecosphere.

Do even the professionals and experts believe in it, in the sense of acting on it in their daily lives? I doubt that they do.

To this science, the body is an assembly of parts provisionally joined, a “basket case” sure enough. A mountain is a heap of “resources” unfortunately mixed with substances that are not marketable...

We may know the anatomy of the body down to the anatomy of atoms, and yet we love and instruct our children as whole persons. And we accept an obligation to help them to preserve their wholeness, which is to say their health. This is not an obligation that we can safely transfer to the subdivided and anatomizing medical industry, not even for the sake of cures. Cures, to industrial medicine, are marketable products extractable from bodies. To cure in this sense is not to heal. To heal is to make whole, and is not so ideologically definable or so technologically possible or so handily billable...

A proper attention to our language, moreover, informs us that the Greek root of “anatomy” means “dissection,” and that of “analysis” means “to undo.” The two words have essentially the same meaning. Neither suggests a respect for formal integrity. I suppose that the nearest antonym to both is a word we borrow directly from Greek: poiesis, “making” or “creation,” which suggests that the work of the poet, the composer or maker, is the necessary opposite to that of the analyst and the anatomist. Some scientists, I think, are in this sense poets.

But we appear to be deficient in learning or teaching a competent concern for the way that parts are joined. We certainly are not learning or teaching adequately the arts of forming parts into wholes, or the arts of preserving the formal integrity of the things we receive as wholes already formed.

Without this concern and these arts, our efforts of conservation are probably futile. Without some sense of necessary connections and a competent awareness of human and natural limits, the issue of scale is not only pointless but cannot even enter our consciousness.

My premise is that there is a scale of work at which our minds are as effective and even as harmless as they ought to be, at which we can be fully responsible for consequences and there are no catastrophic surprises. But such a possibility does not excite us.

What excites us is some sort of technological revolution: the fossil-fuel revolution, the automotive revolution, the assembly-line revolution, the antibiotic revolution, the sexual revolution, the computer revolution, the “green revolution,” the genomic revolution, and so on. But these revolutions — all with something to sell that people or their government “must” buy — are all mere episodes of the one truly revolutionary revolution perhaps in the history of the human race, the Industrial Revolution, which has proceeded from the beginning with only two purposes: to replace human workers with machines, and to market its products, regardless of their usefulness or their effects, to generate the highest possible profit — and so to concentrate wealth into ever fewer hands.

This revolution has, so far, fulfilled its purposes with remarkably few checks or thwarts. I say “so far” because its great weakness is obviously its dependence on what it calls “natural resources,” which it has used ignorantly and foolishly, and which it has progressively destroyed. Its weakness, in short, is that its days are numbered.

Having squandered nature’s “resources,” it will finally yield to nature’s correction, which in prospect grows ever harsher.

We have formed our present life, including our economic and intellectual life, on specialization, professionalism, and competition. Certified smart people expect to solve all problems by analysis, dividing wholes into ever smaller parts. Science and industry do give room to synthesis, but by that they do not mean putting back together the things that they have taken apart; they mean making something “synthetic.” They mean engineering the disassembled parts, by some manner of violence, into profitable new commodities. In such a state of things we don’t see or, apparently, suspect the complexity of connections among ecology, agriculture, food, health, and medicine (if by “medicine” we mean healing). Nor can we see how this complexity is necessarily contained within, and at the mercy of, human culture, which in turn is necessarily contained within the not very expandable limits of human knowledge and human intelligence.

We have accumulated a massive collection of “information” to which we may have “access.” But this information does not become knowledge by being accessible. We might find, if such a computation were possible, that the amount of human knowledge over many millennia has remained more or less constant — that is, it has always filled the available mental capacity — and therefore that learning invariably involves forgetting. To have the Renaissance, we had to forget the Middle Ages. To the extent that we have learned about machines, we have forgotten about plants and animals. Every nail we drive in, as I believe C. S. Lewis said, drives another out.

The thing most overlooked by scientists, and by the enviers and emulators of science in the humanities, is the complicity of science in the Industrial Revolution, which science has served not by supplying the “scientific” checks of skepticism, doubt, criticism, and correction, but by developing marketable products, from refined fuels to nuclear bombs to computers to poisons to pills.

It has been remarkable how often science has hired out to the ready-made markets of depravity, as when it has served the military-industrial complex, which is solidly founded on the hopeless logic of revenge, or the medical and pharmaceutical industries, which are based somewhat on the relief of suffering but also on greed, on the vicious circles of hypochondria, and on the inducible fear of suffering yet to come. The commodification of genome-reading rides upon the same fears of the future that palmistry and phrenology rode upon...

There are, we know, scientists who are properly scrupulous, responsible, and critical, who call attention to the dangers of oversold and under-tested products, and who are almost customarily ignored. They are often called “independent scientists,” and the adjective is significant, for it implies not only certain moral virtues but also political weakness. The combination of expertise, prestige, wealth, and power, incapable of self-doubt or self-criticism, is hardly to be deterred by a few independent scientists.

Scientists in general, like humanists and artists in general, have accepted the industrialists’ habit, or principle, of ignoring the contexts of life, of place, of community, and even of economy.

The capitalization of fear, weakness, ignorance, bloodthirst, and disease is certainly financial, but it is not, properly speaking, economic.

Criticism of scientific-industrial “progress” need not be balked by the question of how we would like to do without anesthetics or immunizations or antibiotics. Of course there have been benefits. Of course there have been advantages — at least to the advantaged. But valid criticism does not deal in categorical approvals and condemnations. Valid criticism attempts a just description of our condition. It weighs advantages against disadvantages, gains against losses, using standards more general and reliable than corporate profit or economic growth. If criticism involves computation, then it aims at a full accounting and an honest net result, whether a net gain or a net loss. If we are to hope to live sensibly, correcting mistakes that need correcting, we need a valid general criticism.

Scared for health, afraid of death, bored, dissatisfied, vengeful, greedy, ignorant, and gullible — these are the qualities of the ideal consumer. Can we imagine an education that would turn passive consumers into active and informed critics, capable of using their minds in their own defense? It will not be the purely technical education-for-employment now advocated by the most influential “educators” and “leaders.”

We have good technical or specialized criticism: A given thing is either a good specimen of its kind or it is not. A valid general criticism would measure work against its context. The health of the context — the body, the community, the ecosystem — would reveal the health of the work.
"[W]e appear to be deficient in learning or teaching a competent concern for the way that parts are joined. We certainly are not learning or teaching adequately the arts of forming parts into wholes, or the arts of preserving the formal integrity of the things we receive as wholes already formed.

Without this concern and these arts, our efforts of conservation are probably futile."
Goes maybe to "the Art of Medicine"? The art of simply living well? (Something we should wish for -- and work for -- all people.)

Great essay. Get a subscription (or just buy a newsstand copy) and read all of it.