Latest HIT news, on the fly...


Saturday, April 19, 2014

Interoperabble update

Report: Lack of Interoperability Limits Meaningful Use Program
April 17, 2014,

Meaningful use stages 1 and 2 fall short of implementing the interoperability among electronic health records that is necessary to facilitate information exchange and develop a robust health data infrastructure, according to a new report from a task force assembled by the MITRE Corporation, Health Data Management reports...

HHS released the report, which was developed by JASON, an independent task force that advises the federal government on issues pertaining to science and technology (DeSalvo, "Health IT Buzz," 4/16). The report was funded by the Agency for Healthcare Research and Quality.

In the report, the task force concluded that the criteria for meaningful use stages 1 and 2 "fall short of achieving meaningful use in any practical sense," adding that "large-scale interoperability amounts to little more than replacing fax machines with the electronic delivery of page-formatted medical records."

According to the task force, "most patients still cannot gain electronic access to their health information," and "rational access to EHRs for clinical care and biomedical research does not exist outside the boundaries of individual organizations."...
Link to the contractor's report here: "A Robust Health Data Infrastructure" (pdf)
1.4 Facing the Major Challenges
A meaningful exchange of information, electronic or otherwise, can take place between two parties only when the data are expressed in a mutually comprehensible format and include the information that both parties deem important. While these requirements are obvious, they have been major obstacles to the practical exchange of health care information.

With respect to data formats, the current lack of interoperability among the data resources for EHRs is a major impediment to the effective exchange of health information. These interoperability issues need to be solved going forward, or else the entire health data infrastructure will be crippled. One route to an interoperable solution is via the adoption of a common mark-up language for storing electronic health records, and this is already being undertaken by the HHS Office of the National Coordinator for Health IT (ONC) and other groups. However, simply moving to a common mark-up language will not suffice. It is equally necessary that there be published application program interfaces (APIs) that allow third-party programmers (and hence, users) to bridge from existing systems to a future software ecosystem that will be built on top of the stored data...
Open the pdf, hit Ctrl-F (PC) or Command-F (for us Mac snobs), search the document for keywords/phrases "dictionary," "data dictionary," "schema," or "RDBMS."

Negative. Zip. Zilch. Nada. Nein. Nyet.

1.5 A New Software Architecture
The various implementations of data formats, protocols, interfaces, and other elements of a HIT system should conform to an agreed-upon specification. Nonetheless, the software architecture that supports these systems must be robust in the face of reasonable deviations from the specification. The term “architecture” is used in this report to refer to the collective components of a software system that interact in specified ways and across specified interfaces to ensure specified functionality. This is not to be confused with the term “enterprise architecture,” referring to the way a particular enterprise’s business processes are organized. In this report, “architecture” is always used in the former sense...
...There would be opportunities to operate within the new software architecture even as it is starting to be implemented. The APIs provide portals to legacy HIT systems at four different levels within the architecture: medical records data, search and index functionality, semantic harmonization, and user interface applications...
"Semantic harmonization"? Lordy. Recall "Rigorability"?

I refer you to another of my posts:

To coin a technical term,


More to come...

Thursday, April 17, 2014

"There is no true value of anything"

- The late W. Edwards Deming.

The broader context of his observation is that, once you go beyond the mere "enumeration" (counting) of discrete objects (and even that gets fraught), you are estimating.


Good stuff. Although some of the algebra will still lose a lot of people. A number of whom will be cherubically grinding healthcare "Big Data" in pursuit of The Next Big Epiphany.

I know my "Sensitivity vs Specificity" and "Bayes" pretty well. See here as well.

Additionally, count me squarely a "Talebist." And, a "Chebyshev"-ist.

"There is no true value of anything."

That applies to "probabilities" as well. When I hear people state "the probability is..." my reflexive reaction is that "you mean your probability estimate is..." Just as with any other type of statistical calculation, so too do "p-values" form distributions. No serious, competent modern analytics practioner takes undergrad axioms such as "set alpha at 0.05" etc seriously anymore. Such conveniences comprise naive methodological dilettantism. You are interested in outcomes differentials, i.e., "expected values" (the multiplied result of prob(x) times the payoff/payout of x) -- the estimated benefit or cost. Just knowing that two means (including regression trendlines) differ "significantly" is of little practical value. We need to be able, as "accurately" as possible estimate the upshot in terms of differential outcomes (be they scientific, clinical, or business/financial.

Knowing such things to finely-grained, stress-tested valuations -- inclusive of assessing "normality" assumptions -- is how Las Vegas makes its money.

The "normal curve" of undergrad stats angst is a model, the expression of a best-case theoretical bi-directionally asymptotically smooth curvilinear exponential function that exists only in theory.
  1. Chance is lumpy.
  2. Overconfidence abhors uncertainty.
  3. Never flout a convention just once.
  4. Don't talk Greek if you don't know the English translation.
  5. If you have nothing to say, don't say anything.
  6. There is no free hunch.
  7. You can't see the dust if you don't move the couch.
  8. Criticism is the mother of methodology.
-Abelson's Laws

Assessing Absolute vs Relative Risk

Say the ambient prevalence of condition "c" is 1 out of 100, or 1%. We select an appropriate  random sample of 2,000 subjects, splitting half via a double-blind RCT experiment into control group CG (no tx) and half into treatment group TG that gets tx "t". We find that the post-treatment prevalence of "c" is 8 of out 1,000 (0.8%), whereas, true to form, there are 10 subjects with condition "c" in the 1,000 person CG (1%).

Well, our tx seems to have reduced the relative risk prevalence by 20%, ja?

Yeah, but the absolute risk reduction estimate from this trial is just one one-hundreth of that, 0.2%

Prevalence matters. Along with these other empirical considerations cited above.

See "Estimating the size of the treatment effect."

More to come...

Dispatch from the Irony-Free Zone

Recent post by Vik and Al on The Health Care Blog. I really like these guys, but I had to call bullshit on this one in the comments.
Kim il Bezos

"Amazon’s system of employee monitoring is the most oppressive I have ever come across and combines state-of-the-art surveillance technology with the system of “functional foreman,” introduced by Taylor in the workshops of the Pennsylvania machine-tool industry in the 1890s. In a fine piece of investigative reporting for the London Financial Times, economics correspondent Sarah O’Connor describes how, at Amazon’s center at Rugeley, England, Amazon tags its employees with personal sat-nav (satellite navigation) computers that tell them the route they must travel to shelve consignments of goods, but also set target times for their warehouse journeys and then measure whether targets are met.
All this information is available to management in real time, and if an employee is behind schedule she will receive a text message pointing this out and telling her to reach her targets or suffer the consequences. At Amazon’s depot in Allentown, Pennsylvania (of which more later), Kate Salasky worked shifts of up to eleven hours a day, mostly spent walking the length and breadth of the warehouse. In March 2011 she received a warning message from her manager, saying that she had been found unproductive during several minutes of her shift, and she was eventually fired. This employee tagging is now in operation at Amazon centers worldwide.

Whereas some Amazon employees are in constant motion across the floors of its enormous centers— the biggest, in Arizona, is the size of twenty-eight football fields— others work on assembly lines packing goods for shipping. An anonymous German student who worked as a temporary packer at Amazon’s depot in Augsburg, southern Germany, has given a revealing account of work on the line at Amazon. Her account appeared in the daily Frankfurter Allgemeine Zeitung, the stern upholder of German financial orthodoxy and not a publication usually given to accounts of workplace abuse by large and powerful corporations. There were six packing lines at Amazon’s Augsburg center, each with two conveyor belts feeding tables where the packers stood and did the packing. The first conveyor belt fed the table with goods stored in boxes, and the second carried the goods away in sealed packages ready for distribution by UPS, FedEx, and their German counterparts.

Machines measured whether the packers were meeting their targets for output per hour and whether the finished packages met their targets for weight and so had been packed “the one best way.” But alongside these digital controls there was a team of Taylor’s “functional foremen,” overseers in the full nineteenth-century sense of the term, watching the employees every second to ensure that there was no “time theft,” in the language of Walmart. On the packing lines there were six such foremen, one known in Amazonspeak as a “coworker” and above him five “leads,” whose collective task was to make sure that the line kept moving. Workers would be reprimanded for speaking to one another or for pausing to catch their breath (Verschnaufpause) after an especially tough packing job.
The functional foreman would record how often the packers went to the bathroom and, if they had not gone to the bathroom nearest the line, why not. The student packer also noticed how, in the manner of Jeremy Bentham’s nineteenth-century panopticon, the architecture of the depot was geared to make surveillance easier, with a bridge positioned at the end of the workstation where an overseer could stand and look down on his wards. 23 However, the task of the depot managers and supervisors was not simply to fight time theft and keep the line moving but also to find ways of making it move still faster. Sometimes this was done using the classic methods of Scientific Management, but at other times higher targets for output were simply proclaimed by management, in the manner of the Soviet workplace during the Stalin era.
Onetto in his lecture describes in detail how Amazon’s present-day scientific managers go about achieving speedup. They observe the line, create a detailed “process map” of its workings, and then return to the line to look for evidence of waste, or Muda, in the language of the Toyota system. They then draw up a new process map, along with a new and faster “time and motion” regime for the employees. Amazon even brings in veterans of lean production from Toyota itself, whom Onetto describes with some relish as “insultants,” not consultants: “They are really not nice. . . . [T]hey’re samurais, the real last samurais, the guys from the Toyota plants.” But as often as not, higher output targets are declared by Amazon management without explanation or warning, and employees who cannot make the cut are fired. At Amazon’s Allentown depot, Mark Zweifel, twenty-two, worked on the receiving line, “unloading inventory boxes, scanning bar codes and loading products into totes.” After working six months at Amazon, he was told, without warning or explanation, that his target rates for packages had doubled from 250 units per hour to 500.

Zweifel was able to make the pace, but he saw older workers who could not and were “getting written up a lot” and most of whom were fired. A temporary employee at the same warehouse, in his fifties, worked ten hours a day as a picker, taking items from bins and delivering them to the shelves. He would walk thirteen to fifteen miles daily. He was told he had to pick 1,200 items in a ten-hour shift, or 1 item every thirty seconds. He had to get down on his hands and knees 250 to 300 times a day to do this. He got written up for not working fast enough, and when he was fired only three of the one hundred temporary workers hired with him had survived.

At the Allentown warehouse, Stephen Dallal, also a “picker,” found that his output targets increased the longer he worked at the warehouse, doubling after six months. “It started with 75 pieces an hour, then 100 pieces an hour. Then 150 pieces an hour. They just got faster and faster.” He too was written up for not meeting his targets and was fired. At the Seattle warehouse where the writer Vanessa Veselka worked as an underground union organizer, an American Stakhnovism pervaded the depot. When she was on the line as a packer and her output slipped, the “lead” was on to her with “I need more from you today. We’re trying to hit 14,000 over these next few hours.”

Beyond this poisonous mixture of Taylorism and Stakhnovism, laced with twenty-first-century IT, there is, in Amazon’s treatment of its employees, a pervasive culture of meanness and mistrust that sits ill with its moralizing about care and trust— for customers, but not for the employees. So, for example, the company forces its employees to go through scanning checkpoints when both entering and leaving the depots, to guard against theft, and sets up checkpoints within the depot, which employees must stand in line to clear before entering the cafeteria, leading to what Amazon’s German employees call Pausenklau (break theft), shrinking the employee’s lunch break from thirty to twenty minutes, when they barely have time to eat their meal…”

Perhaps the biggest scandal in Amazon’s recent history took place at its Allentown, Pennsylvania, center during the summer of 2011. The scandal was the subject of a prizewinning series in the Allentown newspaper, the Morning Call, by its reporter Spencer Soper. The series revealed the lengths Amazon was prepared to go to keep costs down and output high and yielded a singular image of Amazon’s ruthlessness— ambulances stationed on hot days at the Amazon center to take employees suffering from heat stroke to the hospital. Despite the summer weather, there was no air-conditioning in the depot, and Amazon refused to let fresh air circulate by opening loading doors at either end of the depot— for fear of theft. Inside the plant there was no slackening of the pace, even as temperatures rose to more than 100 degrees.

On June 2, 2011, a warehouse employee contacted the US Occupational Safety and Health Administration to report that the heat index had reached 102 degrees in the warehouse and that fifteen workers had collapsed. On June 10 OSHA received a message on its complaints hotline from an emergency room doctor at the Lehigh Valley Hospital: “I’d like to report an unsafe environment with an Amazon facility in Fogelsville. . . . Several patients have come in the last couple of days with heat related injuries.” 

On July 25, with temperatures in the depot reaching 110 degrees, a security guard reported to OSHA that Amazon was refusing to open garage doors to help air circulate and that he had seen two pregnant women taken to a nursing station. Calls to the local ambulance service became so frequent that for five hot days in June and July, ambulances and paramedics were stationed all day at the depot…"

Head, Simon (2014-02-11). Mindless: Why Smarter Machines are Making Dumber Humans (p. 42-44). Basic Books. Kindle Edition.

It gets worse. Lots more about the odious management culture at Amazon. Walmart too.

More to come...

Tuesday, April 15, 2014

Unhappy news

How Being a Doctor Became the Most Miserable Profession

Nine of 10 doctors discourage others from joining the profession, and 300 physicians commit suicide every year. When did it get this bad?

By the end of this year, it’s estimated that 300 physicians will commit suicide. While depression amongst physicians is not new—a few years back, it was named the second-most suicidal occupation—the level of sheer unhappiness amongst physicians is on the rise.

Simply put, being a doctor has become a miserable and humiliating undertaking. Indeed, many doctors feel that America has declared war on physicians—and both physicians and patients are the losers.

Not surprisingly, many doctors want out. Medical students opt for high-paying specialties so they can retire as quickly as possible. Physician MBA programs—that promise doctors a way into management—are flourishing. The website known as the Drop-Out-Club—which hooks doctors up with jobs at hedge funds and venture capital firms—has a solid following. In fact, physicians are so bummed out that 9 out of 10 doctors would discourage anyone from entering the profession.

It’s hard for anyone outside the profession to understand just how rotten the job has become—and what bad news that is for America’s health care system. Perhaps that’s why author Malcolm Gladwell recently implied that to fix the healthcare crisis, the public needs to understand what it’s like to be a physician. Imagine, for things to get better for patients, they need to empathize with physicians—that’s a tall order in our noxious and decidedly un-empathetic times.

After all, the public sees ophthalmologists and radiologists making out like bandits and wonder why they should feel anything but scorn for such doctors—especially when Americans haven’t gotten a raise in decades. But being a primary care physician is not like being, say, a plastic surgeon—a profession that garners both respect and retirement savings. Given that primary care doctors do the work that no one else is willing to do, being a primary care physician is more like being a janitor—but without the social status or union protections.

Unfortunately, things are only getting worse for most doctors, especially those who still accept health insurance. Just processing the insurance forms costs $58 for every patient encounter, according to Dr. Stephen Schimpff, an internist and former CEO of University of Maryland Medical Center who is writing a book about the crisis in primary care. To make ends meet, physicians have had to increase the number of patients they see. The end result is that the average face-to-face clinic visit lasts about 12 minutes...

Lengthy article. Read all of it.
...To be sure many people with good intentions are working toward solving the healthcare crisis. But the answers they’ve come up with are driving up costs and driving out doctors.  Maybe it’s too much to ask for empathy, and maybe physician lives don’t matter to most people.

But for America’s health to be safeguarded, the wellbeing of America’s caretakers is going to have to start mattering to someone.
Copy that.

To what extent does Health IT add to this unhappy state? Yeah, the answer is complex and mixed. to wit,
Medscape Medical News
Meaningful Use Not Correlated With Quality in Study
Ken Terry April 14, 2014

Showing meaningful use (MU) of electronic health records (EHRs) was not correlated with performance on clinical quality measures, according to a new study published online April 14 in JAMA Internal Medicine.

The study, one of the first of its kind, was performed at clinics affiliated with Brigham and Women's Hospital in Boston, Massachusetts. It compared the quality scores of 540 physicians who achieved MU with those of 318 physicians who did not...
Equivocal findings, but worrisome.

More to come...

Sunday, April 13, 2014

CQM am•phib•o•ly (æmˈfɪb ə li)

I've been reviewing the Meaningful Use EP and EH Stage 2 CQMs (Clinical Quality Measures). This one jumped right out on page one, first for the potential Boolean amphiboly ("and" vs "or" vagueness) and then for the fairly extensive internal EHR coding logic (or user-initiated report query logic) it would take to calculate and submit this one measure (of 64).

"Alcohol and Other Drug Dependence"? Taken literally (?), you could see it interpreted as -- to get into the numerator -- I have to have both a reported drinking problem and I admittedly habitually smoke pot, etc. What they really intend is "Alcohol or Other Drug Dependence," right? e.g., see the denominator column on the right: "alcohol or other drug dependency."

Boolean amphiboly goes to the fact that computers are stupid, if consistent. They follow their Boolean logic / Order of Ops rules reflexively. They don't "get" what you "really intended."

Query a database for "...where category = "Cabernet" .and. volume = "750" .and. price = 9.99 .and. price = 10.99..."

You get zero items in the search results. You really meant ".or." as it goes to price. You wanted to see a list of all 750 ml bottles of Cab priced at exactly either $9.99 or $10.99.

I learned my amphiboly lessons the hard way, writing computational code in a forensic-level radiation lab in Oak Ridge in the 80's, where the consequences of error were immediate and severe.

Sloppy use of language leads to sloppy thinking (and the other way around). Boolean amphiboly remains a major reason we have bugs in software.

Below, Soapware addresses NQF 0004.

"Chemical dependency issues." Alcohol "and" other psychoactive substances all rolled up into one "dependency" syndrome -- via ".or." logic under the hood.

It'd be one thing if CMS or NIST were delivering standardized plug 'n play "black box" software functions to the EHR vendors to be embedded in their respective products, but, given the lack of a standard data dictionary and hundreds of differing RDBMS schema, that cannot be the case. Everyone has to code their own proprietary CQM computational and reporting functionalities. All we can do is hope that the 2014 CEHRT process verifies the accuracy of the CQM I/O for each certified product.

You comfortable with that?


Couldn't help the play on the late Stephen Jay Gould's essay title.

NQF 0495

The "median," recall, is the midpoint of a distribution that has been sorted and ranked from smallest to largest value. to wit,
1  2  3  4  5  6  7  8  9
The median is 5, the precise midpoint, with four values on either side (as is the arithmetic average in this case: 45/9=5). Where the array contains an even number of items,
1  2  3  4  5  6  7  8  9  10
The median here is 5.5 (you "interpolate" by averaging the two central values, 5 and 6). Again, in this case, the arithmetic average is the same as the median, 5.5. For this discussion, we could think of these as "hours to admission from entry to the ER." Probably wouldn't be far off, lol...

We use medians in lieu of averages where the "weighting"/biasing effect of extreme high or low values would misleadingly skew the simple average "central tendency" measure.

e.g., say employer I.B. Gready has 9 workers, each of whom is paid $10,000 per year. He pays himself $910,000 a year. Total payroll, then, is a million dollars. "Average" salary is an impressive $100k ($1M/10).

Median salary, though, is still $10k, representative (exactly in this case) of what everyone but I.B. Gready earns.

Using a median for this CQM is no doubt appropriate, but I question the utility of just reporting the median. From an Ops improvement perspective, I'd want to see the entire distributions from low to high, the range, the skew, the kurtosis ("fat" or "thin" "tails"). I'd want to be looking for "special cause" variabilities -- correlations indicative of contingent process suboptimalities. Two hospitals might report quite similar medians, but one experiences extreme volatility whereas the other has only a tight, relatively more predictable variability (the "sigma"). You'd want to know why.

Simply reporting medians tells us way less than we need to know for QI. Again, the coding logic for these measures can be rather complex. Are we getting actionable value for the efforts. If not, we're in Quadrant Three ("Urgent but not Important").

Measuring and reporting CQMs helps to ensure that our health care system is delivering effective, safe, efficient, patient-centered, equitable, and timely care.
One hopes. How about some outcomes measures? I know that these CQMs are "proxies" -- it's assumed that if you minimally do X, Y, Z, A, B, C, D, E, and F and report on them to the feds, better patient outcomes will eventually follow.

A leap, IMO.

BTW, eClincalWorks has a nice tabulation of the CQMs here.


Saw this in a LinkedIn email.

Expat gigs in the Middle East are gravy postings. Tax-free salary.

More to come...

Thursday, April 10, 2014

HHS Secretary Sebelius resigns

From USA Today
WASHINGTON--After a difficult five years shepherding President Obama's signature health care law, Health and Human Services Secretary Kathleen Sebelius has tendered her resignation, according to two senior administration officials.

Obama accepted the resignation this week and intends to announce that he will nominate Office of Management and Budget Director Sylvia Mathews Burwell to replace Sebelius.

He will make the formal announcement at 11 a.m. on Friday at the White House, according to officials, who asked not to be identified so as not to preempt the president.

In recent months, Sebelius has faced heavy scrutiny after the troubled launch of the federal online insurance marketplace, and has been deluged with Republican attacks over the costs of the Affordable Care Act...
Not sure I'd want that job. Burwell will have a circus confirmation hearing.

John Halamka, M.D., CIO, Beth Israel Deaconess Medical Center & co-chair of the HIT Standards Committee:

“I want to thank Kathleen for the challenging work she’s done that laid the foundation for the years of healthcare reform implementation ahead. During her transition, I’ll stay focused on the road ahead. For me, every day is Meaningful Use, ICD-10 (yes, we’ll finish it), ACA, and HIPAA Omnibus Rule.”


Sebelius Departure from HHS Will Have Negligible Effect on HIT

With all the problems that have plagued the rollout and operation of the federal exchange website, the announcement that Kathleen Sebelius has decided to resign as Secretary of Health and Human Services makes perfect sense. Sebelius is trying to leave on a "high note," timing her resignation with the end of open enrollment on March 31, which marked the milestone of an estimated 7.5 million Americans having signed up for healthcare coverage under the Affordable Care Act.

During her five-year tenure, Sebelius presided over a government behemoth at HHS, helping to usher in a host of new programs expected to improve the quality and efficiency of care. President Obama in 2009 signed the HITECH Act to lay the ground work for an information technology infrastructure to support health reform, which came a year later through the Affordable Care Act.

Now, five years later, about $24 billion has been spent on driving EHR adoption--$22 billion on the Medicare and Medicaid incentive program and $2 billion on other programs--which has resulted in a dramatic increase in EHR use among eligible professionals and eligible hospitals. However, for all her leadership at HHS, Sebelius did not have hands-on involvement in the day-to-day design and implementation of the health IT initiatives that are driving adoption among healthcare providers, and it is for this reason that her departure will have a negligible effect on those ongoing efforts...

FRIDAY, APR 11, 2014 09:17 AM PDT
A pro- single payer doctor’s concerns about Obamacare
Believe me, the right's approach would be much worse. But the underinsured are getting a worse deal than you think


As a single-payer advocate who is also a doctor, I was concerned after the Affordable Care Act was passed that it didn’t do enough to combat rising underinsurance. A recent study by the Commonwealth Fund, which used new data to demonstrate that in 2012 some 31.7 million Americans were underinsured (i.e. insured, but still with heavy additional out-of-pocket health care expenses), argued that the burden of underinsurance will likely lessen as the ACA fully unfolds. But is there really reason for such optimism?

This is a complicated issue with many moving parts, so one way to tackle it (before immersing ourselves in the exhilarating policy literature) is to pose a simpler question: if your family is insured, and someone gets seriously sick, can you not worry about going broke?

The short answer: it depends on how much you have in the bank, and on the “out-of-pocket maximum” established by the ACA for your particular plan. The out-of-pocket maximum is the most that you would have to pay (after premiums) on things like co-pays for medications or deductibles for hospitalizations, and it can go as high as $12,700 annually for exchange plans under the ACA. But doesn’t the law provide protection for lower-income individuals, for instance, in the form of reduced out-of-pocket limits? The answer is yes – but to a lesser extent than we initially thought, even though, somehow, no one informed us that things had changed...
Interesting post. Read all of it. See my 2009 "Pubic Optional." We keep calling it "insurance," but it's still mostly "prepayment" via for-profit intermediaries. As medical economist J.D. Kleinke says, ObamaCare is a "radical expansion of the status quo."

Below, we're gonna keep reading and hearing this stuff ad nauseum for two more years.



See my review of Mario Bunge's historical "Medical Philosphy" in my prior post "Philosophia sana in ars medica sana."

More to come...

Wednesday, April 9, 2014

I'm seriously overbooked

Well, I just finished this book. Several others came in and jumped the rope line (e.g., "Mindless," "Flash Boys," "The Seven Sins of Wall Street," "Capital in the 21st Century") 

You ought to get it and read it (and pay it forward). Again, my larger concern has long been that we focus too much on technological and process improvements at our policy peril. Toxic organizational dynamics and socioeconomic considerations (the latter addressed at cogent length in The American Health Care Paradox) are equally important, IMO.

Concluding excerpts:

How could the United States devote so much money to health care and yet rank so poorly relative to other industrialized countries in key indicators of the nation’s health? Per capita, the United States spends nearly double what some of its peers spend, but Americans lag behind in terms of life expectancy, infant mortality, low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted diseases, HIV/ AIDS, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disability rates ... We have suggested that previous calculations have omitted an aspect of spending that is critically important for national health outcomes. This is spending on social services, an area in which the United States spends far less relative to its GDP than its peer countries. The new math unraveled the paradox. If we add together what countries spend on health care and what they spend on social services, the United States’ place in the ranking of industrialized countries shifts considerably. This sum of spending is what might be called the national investment in health. In looking at the sum, no longer does the United States appear to be a massively big spender. Americans’ spending on social services is far less per capita than that of counterpart countries...

This finding is consistent with what experts in public health have argued for decades: health is determined by far more than good genes and medicine...

A comparative analysis of Scandinavian and American values, however, reveals the depths of the United States’ challenges in casting a health care model to improve its population’s health. Although Scandinavians and Americans shared similar views about personal freedom, competition, political action, and investment in technology, conceptions of health differ markedly... Americans lack the trust in each other and in government enjoyed in Scandinavia. This distrust may explain the American resistance to shared accountability for health needed to address the social, environmental, and behavioral determinants of ill health...

IN THE YEARS WE HAVE spent conceiving of and writing this book, we have had ample time to consider the criticisms its ideas may face. We have wrestled with our own, similar doubts from time to time. We have wondered if the scope of the work is too large, the goals too lofty, or the implications too dire. At the same time, we have wondered whether we paid adequate attention to certain flash-point issues, such as mental health and chronic illness, which represent obvious intersections of health and social services. Reconciling and, at times, adapting our views in light of these concerns has been a meaningful exercise that strengthened the logic of our thinking. No doubt, the challenges that lay ahead are considerable, but confronting the deep roots of the spend more, get less paradox is a productive step toward effective reform. At this stage, we thought it wise to include discussion of some of the most pressing and enduring issues, which could not be fully addressed here, to prompt among readers a more authentic analysis of and continued discourse about core challenges ... we worry that some readers will become impatient with the lack of a quick fix, and hence withdraw from the national dialogue surrounding national health investment strategy. Last, we are concerned that readers will recognize the advantages of a more holistic approach to health but find the economic reordering that might ensue unpalatable, despite the promise of sustained benefits...

Although the scientific literature provides robust evidence regarding the influence of social, environmental, and behavioral factors on people’s health, 5 comprehensive evaluations that quantify the precise costs and health impacts of broad-based, nonmedical health interventions are less available. Solid housing, a nutritious diet, stable home life, a reasonable amount of sleep, and a steady job have all been linked to improved health so many times6 that the studies are becoming uninteresting for new researchers to pursue ... Unemployed and underemployed segments of the population have been shown to die younger and be in worse health throughout their lives than are those more gainfully employed, and this finding is persistent across countries and times.

More relevant for our purposes, studies are beginning to show that increased education can lower health care spending. For instance, in a study of older adults with asthma or hypertension, those with more versus less education were significantly less likely to be high spenders in health care. A recent Robert Wood Johnson Foundation report highlighted research that demonstrated that lack of college education accounted for up to 35 percent of the variation in premature death rates in the United States, and each added year of postsecondary school education was associated with a 16 percent decline in years of life lost before the age of seventy-five...

The desire for certainty is in part an artifact of the scientific approach to health care. The scientific method calls for researchers to establish controlled experiments that provide unbiased and generalizable conclusions. These standards are considered appropriate for biomedical research, but can be unduly constraining in a study of complex human behavior that is replete with any number of dynamic and unpredictable processes. Reducing such complexity to a controlled intervention to which people are assigned randomly, or to a reliable set of quantifiable values, is often an impossible challenge...

...while the scientific approach has fueled unprecedented medical and technical progress in many arenas, it has been of less value in conferring data that identifies a prescription for optimally addressing the multifaceted causes of ill health. Scientific methods are touted for their ability to identify the effect of a specific treatment controlling for all the other social, environmental, genetic, and lifestyle factors that might influence the health outcome. In examining broad health interventions, however, recognizing the impact of these larger factors is critical. What might be dismissed as a factor to control in a biomedical experiment, such as the presence of a family support system, is often a fundamental facet of the intervention from a complex systems perspective...

To address the challenge of multiple moving parts at once, researchers often turn to statistical regression analysis, which seeks to distill effects of jointly occurring factors into their component parts. Yet, these methods are less powerful in the face of feedback loops and nonlinear effects inherent in complex systems. As James Gleick, author of Chaos: Making a New Science, writes, “Linear equations are solvable . . . [They] have an important modular virtue: you can take them apart and put them together again. The pieces add up. [But] nonlinear systems generally cannot be solved and cannot be added together. Nonlinearity means that the act of playing the game has a way of changing the rules.”

All this is to say nothing of the ethical challenges researchers confront performing studies in which key social services are withheld from participants in need so as to study their impact on health...

Additionally, we worry that readers will misconstrue the implications of our analysis as little more than a call for more robust safety net services to complement the current health care sector. This would be a misinterpretation of our work. The data we have outlined and the reasoning we have presented are relevant for all Americans, regardless of income bracket. As already noted, the discrepancy in health between the United States and its peer countries is apparent even among wealthy, well-educated, and white subgroups of the American public...

Certainly, for people who are poor, social services, such as housing, nutrition, and safe neighborhoods, are essential. Often, these services must be financed by taxes or philanthropy and supported by governmental policy and action. Hence, our reference to social services may summon for some readers images of government handouts, the “dole,” and bloated bureaucracies...

We anticipate that some readers will become immobilized by the complexity of the issues and will settle for responding haphazardly to the matters at hand rather than seeking a strategic approach ... Some would say this is the American way. Speaking to this point, one health and wellness center service user (ID 59) declared:

The United States is the ultimate in ADHD [attention deficit/ hyperactivity disorder] investing. [LOL, what have I been saying? -BG]
The American preference for focusing on the immediate or impending source of pain without attending to underlying causes reflects a type of national investment myopia. This term refers to conditions in which people focus so intently on one aspect of a problem that they neglect other critical data in the landscape. Steven Most and Brian Scholl, professors of psychology at Harvard and Yale University, respectively, have referred to this phenomenon as “inattentional blindness.” ... Generally speaking, Americans are an impatient and skeptical lot, focused mostly on actions that will render immediate and impressive results...

Nevertheless, we purposefully have avoided offering straightforward solutions for which we recognize the public is thirsty. If our book disappoints in this way, it is because of our deep belief that simple prescriptions will not be effective. Rather, we believe that changing the dialogue around health to be holistic and inclusive of nonmedical contributions is paramount to resolving the spend more, get less phenomenon in American health care. Only in the wake of such a shift will scalable and sustainable solutions emerge.

Increased public dialogue about the consequences of overreliance on individualism and medical approaches, and underinvestment in social capital, may help the country to recognize that the difference of opinion among Americans, regarding whether health is better addressed through individual or collective action, represents a tension to manage, rather than a problem that can be solved. Going forward, Americans would be wise to accept responsibility for patiently managing this tension, rather than aggressively aiming to solve a fictitious problem.

In calling for a reconsideration of social services and social capital in the United States, we are grappling with a timeless tension between individualism and community orientation...

A final concern is that some readers will find the economic consequences of slowing health care expenditure too great a price to pay for better health nationally. The US health care industry has evolved to serve a purpose. Occupying 17.9 percent of the GDP in 2012 and employing one in eight working Americans, 24 the health care industry returns significant profit for any number of professional guilds, health care organizations, and publicly traded corporations. If embracing a holistic vision of health and developing shared accountability results in a shift of funds from health care to social services or a repurposing of health care funds to achieve population health outcomes, a substantial number of Americans may stand to lose...

We do not disagree with the statement that Americans spend more on health care and have worse health outcomes than our peer countries. But we do disagree with the common belief that the solution to this problem lies in reforming the health care sector in isolation...

No health care system in the world is perfect. All have advantages and disadvantages, and all manage the tensions inherent in rationing schemes built into the fabric of their designs. For the most part, the approach to promoting health that countries employ reflects the value base of their citizens. For decades, the United States has relied on reforming various methods of paying for health care or organizing its delivery, when in fact the problem has run deeper. Larger change, extending well beyond the scope of traditional health policy, will be required...

Recognizing its social, environmental, and behavioral dimensions and embracing the need for both personal and shared accountability to address these elements of health runs counter to the American affinity for individualism and threatens a large, profitable medical industry.

It remains an American choice to forego taking bold action and to continue instead on the current path; however, the monumental costs associated with preserving the status quo continue to grow, and relief from the national health burden is unlikely without a new approach. To devise this new approach on the basis of evidence rather than ideology would represent a courageous step in the history of American health policy. To that end, an ever-growing body of literature suggests that broadening Americans’ historically narrow focus on medicine in pursuit of improved national health may ultimately hold the key to unraveling the spend more, get less paradox.
This is an excellent piece of work. Of particular interest is their detailed assessment of the Scandanavian nations Denmark, Norway, and Sweden. We share much more in common with these countries in terms of political, cultural, and economic philosophies than in commonly believed (a reality sure to be summarily dismissed by our willfully ignorant wingnut partisans, to be sure). We would do well to adopt many of their health care system funding, governance, and organizational practices.

I am blessed to have a number of Swedish and Norwegian friends and acquaintances. I find them uniformly among the most amiable, calm, industrious, and creative people I know.

The endnotes documentation in Bradley and Taylor's book just seems to go on forever. I read all the way through them. e.g.,
42. The Gini coefficient in this context is a measure of income inequality. A Gini coefficient of zero expresses perfect equality, where all values are the same. A Gini coefficient of one (100 on the percentile scale) expresses maximal inequality among values; R. V. Burkhauser et al., “Estimating Trends in US Income Inequality Using the Current Population Survey: The Importance of Controlling for Censoring,” Journal of Economic Inequality 9 (2011): 393– 415; Census Bureau, Historical Income Tables: Income Inequality Table H-4 (Washington, DC: US Census Bureau, 2011); OECD, OECD Factbook 2011– 2012 (Paris, France: OECD Publishing, 2011).

57. In his New Year’s Address on January 1, 2013, by the prime minister of Norway, Jens Stoltenberg, agreed with the notion that the American Dream may be easier to achieve in Norway, saying, “The Americans have their American Dream. We have the Norwegian model. Our model may not sound as exciting, but it makes up for this by providing security. In a society where freedom goes hand in hand with security, more people are able to realize their dreams. What I am saying is this: It is easier to realize the American Dream in Norway than it is in America. We should be proud of this.” (Oslo, Norway: Office of the Prime Minister, 2013), accessed February 27, 2013, http:// en/ dep/ smk/ Whats-new/ Speeches-and-articles/ statsministeren/ statsminister_jens_stoltenberg/ 2013/ prime-minister-jens-stoltenbergs-new-yea.html? id = 710868.

3. “Total quality management” (TQM) is a management approach to long-term success through achieving customer satisfaction. In a TQM effort, all members of an organization participate in improving processes, products, services, and the culture in which they work. http:// learn-about-quality/ total-quality-management/ overview/ overview.html. 

“Six Sigma” at many organizations simply means a measure of quality that strives for near perfection. Six Sigma is a disciplined, data-driven approach and methodology for eliminating defects in any process— from manufacturing to transactional and from product to service. http:// new-to-six-sigma/ getting-started/ what-six-sigma/. 

“Toyota Lean” describes a philosophy that incorporates a collection of tools and techniques into the business processes to optimize time, human resources, assets, and productivity, while improving the quality level of products and services to their customers. http:// manufacturing/ lean/ column/ leanjun01. htm. Some of these, particularly TQM and Toyota Lean, originated in Japan. For more reading in this area, see W. E. Deming, Out of the Crisis (Cambridge, MA: MIT Press, 1986); K. Ishikawa, What Is Total Quality Control? The Japanese Way (Upper Saddle River, NJ: Prentice Hall, 1985); A. V. Feigenbaum, Total Quality Control (New York: McGraw-Hill, 1991); J. M. Juran, Juran on Leadership for Quality: An Executive Handbook (Detroit, MI: Free Press, 1989).

33. R. C. Fox, “The Medicalization and Demedicalization of American Society,” Daedalus 106, no. 1 (1977): 9– 22; I. Illich, A. Cochrane, and R. Williams, Medical Nemesis (Sydney, NSW: Australian Broadcasting Commission, Science Programmes Unit, 1975); H. Waitzkin and J. D. Stoeckle, “Information Control and the Micropolitics of Health Care: Summary of an Ongoing Research Project,” Social Science & Medicine (1967) 10, no. 6 (1976): 263– 76; H. Waitzkin and B. Waterman, “Social Theory and Medicine,” International Journal of Health Services 6, no. 1 (1976): 9– 23; P. Conrad, Identifying Hyperactive Children: The Medicalization of Deviant Behavior (Lexington, MA: Lexington Books, 1976), xvi, 122.
19. The IOM Report of 2009, For the Public’s Health: Investing in America’s Future, highlighted the woefully inadequate investment in public health and recommended doubling the investment and stabilizing Congress’s financial commitment to public health services. The United States devotes less than half of 1 percent of the $ 2.5 trillion spent on health care per year to public health efforts. The sentiment we describe is noted in Theodore Brown’s history of public health, which describes the national support for public health as occurring only in times of crisis and fear of epidemics, bioterrorism, and the like, rather than as a constant source of support for a healthy population. E. Fee and T. M. Brown, “The Unfulfilled Promise of Public Health: Déjà Vu All Over Again,” Health Affairs, 21, no. 6 (2002): 31– 43.
Kudos to these authors for doing all of this voluminous research and publishing this book. Whether it gets any policy traction amid our current Clown Car political Idiocracy environment remains to be seen. One certainly hopes so. Had I the money, I'd buy a copy for every member of Congress.
As my regular readers know, I cite a ton of books, news, and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length (albeit still relatively small excerpts, percentage-wise). I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

It is conventional in the press to cite short snips -- a sentence or two -- and then opine on them at length. I cite authors' works because I think they provide information of clear value having no need of my oh-so-wise clarification. I let them speak for themselves without my Bible-thumping interpositions. I am not a Preacher.

Below, some of my recent healthcare related reading list, spanning the gamut from technology and process QI through clinician cognitive burden issues and organizational factors to socioeconomic considerations (the principal topic of the Bradley-Taylor book cited above). I've discussed some of these on the blog from time to time, starting with my total tech fav.


I should be getting click-through money for all these cites, lol...

One more book on the way via Amazon Prime. Should be here today (Friday, 11th).

A quick diversion back to my other Jones, financial fraud. I have her book "It Takes a Pillage" on my Kindle. Excellent writer.

More to come...