Monday, May 2, 2016

"Better, Smarter, and Healthier" Really?

Been plowing through the new NPRM (Notice of Proposed Rulemaking, pdf) for MACRA ("Medicare Access and CHIP Reauthorization Act of 2015" pdf). 1,000+ pages of MEGO (962 pages in the NPRM alone).


Not a lotta love out there for MACRA et al these days in some quarters. See, e.g., "The Angry Physician" at THCB.
...It took me two years to realize the meaninglessness of meaningful use. I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trash bin. I still held out hope.  I thought – this was a first draft, improvements would come. What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down. There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march. Except the road would no longer be paved and we would be walking uphill.

I watched as reimbursements were cut to physician practices, while hospital reimbursements were left alone. Independent practices collapsed only to reemerge in a hospital employed model. The landscape was changing seismically – and yet I saw no evidence that patients were safer, or that this new model was more cost efficient.

It is in this setting that MACRA arrives.  MACRA is the newest iteration of tying reimbursement to value instead of volume. An admirable goal that is spelled out in a 962 page document...
BTW: Peruse the comments in particular. Will MACRA largely be the Zombie Son of MU? Will "better, smarter, healthier" come in significant measure from HHS policy promulgations? Or in spite of them? Will health care become "essentially free, once delivered by the flawless AI-enabled robots in a decade or so" as the exuberant peeps at Singularity University would have us believe? Beyond tech per se, what will be the overlapping (and often confounding) impacts of policy and economics? (apropos, see Steve Findlay's "Measuring Hillary.")

Following on my recent reads concerning the myriad facets of "disruption," I've started a new one:

Dilemmas: Old and New
Britannica and Matson were both successful firms that faced disruption in the form of a new technology. In both cases, the industry was completely transformed by that new technology. However, while Britannica became a disrupted firm, Matson sailed on. Unpacking why their fates were so different is the purpose of this book.

While it is hard to compare encyclopedias and ocean shipping, there are similarities in the Britannica and Matson cases. As already noted, each faced a new technology that transformed their respective industries. Importantly, the senior management in both firms realized the potential of the new technology and sought early on, well ahead of most in the market, to enact strategies to respond to it. However, Britannica and Matson took distinct approaches in implementing that response. Understanding those different choices and their implications is the key to seeing how to deal with disruption.

Britannica and Matson faced variants of what has become known as “the innovator’s dilemma.” While the term was coined and explored by Clayton Christensen in his famous 1997 book of that title, the dilemmas have been posed in various forms through the academic literature on management both prior to Christensen and also contemporaneously with him. The dilemma an established firm faces when dealing with disruption—usually in the form of a new technology or innovation—is that seemingly good management practices not only can fail to deal with disruption but can, in fact, be a hindrance in finding a way of dealing with it. When Britannica explored digital technologies in the mid to late 1980s, its main encyclopedia business was thriving, and accommodating a digital product would require reengineering the entire organization. As a consequence, its approach was to wall off its digital endeavors, allowing them to be pursued freely in an autonomous unit. Matson faced the same organizational issues in adopting containerization for its shipping fleet, but rather than creating a separate unit to pursue this, from the start it adopted a new organizational structure that tightly integrated research and commercial divisions. Thus, it exposed the entire organization to change and in the process faced a slower path to adopting containerization.

The difference between dealing with disruption via a walled-off, independent unit and doing so with a more tightly integrated organizational structure is at the center of this book. To be sure, the independence path has received the most attention in recent times, due to its advocacy by Clayton Christensen under the mandate of disrupting one’s own company before a competitor does. However, the integration path stemmed from a distinct approach to analyzing disruption that emerged at the same time as Christensen’s. This approach was put forward mainly by Rebecca Henderson. Both Christensen and Henderson were Harvard PhD students around 1990, both looked at what we now call disruption as part of their seminal thesis work, and today both are professors at Harvard Business School. How they came to such distinct viewpoints will be covered later in this book.

To anticipate where this journey will take us, we will see that independence as a means of dealing with disruption has some inherent flaws that undermine its effectiveness. This is both theoretically the case—as every independent unit eventually needs to be integrated into the mainline organization, creating the very conflicts it was set up to avoid—but is also true as part of the historical record—very few firms have used independent units to successfully avoid disruption.

The track record on dealing with disruption via an integrated organizational structure is, in my opinion, stronger but itself leads to a new dilemma. To stave off disruption, integration comes with a price. Organizations that have integrated ways of dealing with radical technological change tend to be slower-moving and also tend, at any given point in time, not to operate at their most efficient. Consequently, while they tend to be long-lived and shielded when there are multiple disruptive waves, they tend not to lead or dominate their markets. Thus, a core dilemma firms must grapple with is whether to integrate for sustainability or adopt alternative structures to gain more transient but profitable market positions...

Gans, Joshua (2016-03-18). The Disruption Dilemma (MIT Press) (Kindle Locations 244-263). The MIT Press. Kindle Edition.
Also just downloaded this one.

"Had I, or my physicians, known what disruptive technologies would be impacting medicine in just the next few years, I may not have had three organs removed." [pg. 21]
Recall that Robin was one of the speakers at last week's 5th Annual AARP Health Innovation@50+ LivePitch™ event.
A convergence of technologies is happening in medicine. We’re entering a perfect storm of technological advancements that are enabling the era of the patient. We’re now in an era of not only patient-focused care but also patient-directed medicine [pg 19].



This book gives you a whiplash Six Flags roller coaster tour through a broad swath of cutting-edge health tech innovation.
I’ve sat down and spoken with almost all of the people mentioned in this book. We talk tech, trends, science, entrepreneurship, and healthcare. I attended the majority of presentations at Singularity University for over three years. I took dives into major areas of accelerating technology, including robotics, computing systems, biology, nanotechnology, artificial intelligence, future studies, space, global challenges, incentivized prizes, and entrepreneurship. I took very deep dives into medicine. I’ve spoken at, organized, or attended many other educational channels in medicine, biology, and technology, including Arc Fusion Programs, Health 2.0, TEDMED, TED, Connected Health Symposium, Differential Medicine, and workshops on tissue engineering and organ banking for the White House and DARPA with the Organ Preservation Alliance, among many others. I’ve listened to literally thousands of hours of content on technology, medicine, and science outside of my formal education. I’ve taken that knowledge and broken it down for you, as told through the eyes of a patient, to show just how rapidly medicine is changing, empowering, and enabling the patient to be a key decision maker [pp 22-23].
The Future of the Hospital
A lot of what happens in a hospital today is going to happen in the future in the patient’s home or at a nearby pharmacy or storefront clinic. All the point of care diagnostics, the sensors, the wearable technology, the cloud-based computing, the telepresent robots, and technology we haven’t even thought of yet will converge to make hospitals places where you will go a lot less often. Even people with chronic diseases and severe handicaps will be able to get excellent medical care without leaving home. And people who live far from advanced medicine will still be able to access it. 

When I was growing up in New Hampshire, our small town didn’t have a hospital. The closest hospital was several towns over. Specialists and more advanced hospital care were a long drive away. I sometimes forget how lucky I am now to live in California and be surrounded by high-end hospital systems like Stanford and UCSF and PAMF. I didn’t have that access when I was younger. Many people still don’t. If you’re in rural Wyoming, you might need to drive for hours to see a doctor. And if you live in rural parts of Africa or India or anyplace where the nearest doctor could be a two- or three-day walk away, your access to high-level medical care is basically nonexistent. The medicine of the future will give the world access to healthcare [pp 149-150].
Let's hope that all of this beneficent whiz-bang will indeed be universally affordable. The question remains: how will all of this get paid for?

Both of the foregoing books are more fun (and more usefully informative) than the MACRA NPRM. to wit,
[NPRM pg 36] … On October 16, 2015, ONC published the 2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications final rule ("2015 Edition final rule"). The final rule made changes to the ONC Health IT Certification Program that strengthen the testing, certification, and surveillance of health IT. In addition, the final rule clarified and expanded the responsibilities of ONC-Authorized Certification Bodies (ONC-ACBs) with respect to the surveillance of certified EHR technology and other health IT certified under the ONC Health IT Certification Program, including requirements for ONC-ACBs to conduct more frequent and more rigorous surveillance of certified technology and capabilities “in the field” (80 FR 62707). The purpose of in-the-field surveillance is to provide greater assurance that health IT meets certification requirements not only in a controlled testing environment but also when used by health care providers in actual production environments (80 FR 62707).

In addition to these changes, on March 2, 2016, ONC published the ONC Health IT Certification Program: Enhanced Oversight and Accountability proposed rule, which would expand ONC’s role to strengthen oversight under the ONC Health IT Certification Program by providing a means for ONC to directly review and evaluate the performance of certified health IT in certain circumstances, such as in response to potential systemic or widespread issues, or in response to problems or issues that could pose a risk to public health or safety, compromise the security or privacy of patients’ health information, or give rise to other exigencies (81 FR 11055).

These efforts to strengthen surveillance and other oversight of certified health IT, including through expanded in-the-field surveillance and ONC direct review of technology and capabilities, are critical to the success of HHS programs and initiatives that require the use of certified health IT to improve health care quality and the efficient delivery of care. With respect to the use of certified EHR technology under the Medicare and Medicaid EHR Incentive Programs and the MIPS Program, effective surveillance and oversight is fundamental to providing basic confidence that such technology consistently meets applicable standards, implementation specifications, and certification criteria adopted by the Secretary when it is used by eligible clinicians, EPs, eligible hospitals, and CAHs, as well as by other persons with whom eligible clinicians, EPs, eligible hospitals, and CAHs need to exchange electronic health information to comply with program requirements. The need to ensure that technology consistently meets applicable standards, implementation specifications, and certification criteria is important both at the time it is certified and on an ongoing basis when it is implemented and used in the field by eligible clinicians, EPs, eligible hospitals, and CAHs in order to meet objectives and measures under the Medicare and Medicaid EHR Incentive Program or MIPS. Efforts to strengthen surveillance and oversight of certified EHR technology in the field will become even more important as the types and capabilities of certified EHR technology continue to evolve and with the onset of Stage 3 of the Medicare and Medicaid EHR Incentive Programs and MIPS, which include heightened requirements for sharing electronic health information with other providers and with patients using a broad range of certified EHR technology and other health IT. Finally, we note that effective surveillance and oversight of certified EHR technology is necessary if eligible clinicians, EPs, eligible hospitals, and CAHs are to be able to rely on certifications issued under the ONC Health IT Certification Program as the basis for selecting appropriate technologies and capabilities that support the use of certified EHR technology while avoiding potential implementation and performance issues.

For all of these reasons, the effective surveillance and oversight of certified health IT, and certified EHR technology in particular, is necessary to enable eligible clinicians, EPs, eligible hospitals, and CAHs to demonstrate that they are using certified EHR technology in a meaningful manner as required by sections 1848(o)(2)(A)(i) and 1886(n)(3)(A)(i) of the Act. Yet as ONC observed in the 2015 Edition final rule, such surveillance and oversight will not be effective unless EPs, eligible hospitals, and CAHs are actively engaged and cooperate with the authorized surveillance and oversight of their technology, including by granting access to and assisting ONC and ONC-ACBs to observe the performance of production systems (80 FR 62716).

Accordingly, we are proposing that as part of demonstrating that it is using certified EHR technology in a meaningful manner, an eligible clinician, EP, eligible hospital, or CAH must demonstrate its cooperation with these authorized surveillance and oversight activities. We are proposing to revise the definition of a meaningful EHR user at §495.4, as well as the attestation requirements at §495.40(a)(2)(i)(H) and §495.40(b)(2)(i)(H) to require EPs, eligible hospitals, and CAHs to attest their cooperation with certain authorized health IT surveillance and direct review activities, described in more detail in this section of the rule, as part of demonstrating meaningful use under the Medicare and Medicaid EHR Incentive Programs. Similarly, we are proposing to include an identical attestation requirement in the submission requirements for eligible clinicians under the advancing care information performance category proposed at §414.1375.

We propose that eligible clinicians, EPs, eligible hospitals, and CAHs would be required to attest that they have cooperated in good faith with the surveillance and ONC direct review of their health IT certified under the ONC Health IT Certification Program, as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT. Under the terms of the attestation, such cooperation would include responding in a timely manner and in good faith to requests for information (for example, telephone inquiries, written surveys) about the performance of the certified EHR technology capabilities in use by the provider in the field. The provider’s cooperation would also include accommodating requests (from ONC-Authorized Certification Bodies or from ONC) for access to the provider’s certified EHR technology (and data stored in such certified EHR technology) as deployed by the provider in its production environment, for the purpose of carrying out authorized surveillance or direct review, and to demonstrate capabilities and other aspects of the technology that are the focus of such efforts, to the extent that doing so would not compromise patient care or be unduly burdensome for the eligible clinician, EP, eligible hospital, or CAH.

We understand that cooperating with in-the-field surveillance may require prioritizing limited time and other resources...
Lordy. A quick NPRM priority keyword/phrase-of-interest tally:
  • EHR(s) --  659
  • CEHRT --  135
  • "quality measures" -- 338
  • "Meaningful Use" -- 56
  • "quality improvement" -- 42
UPDATE: Healthcare Dive has a nice analytic summary of the MACRA NPRM here, "Breakdown of the MACRA Proposed Final Rule."
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NEW AT EHR SCIENCE
Primary Care—Leading the HIT Revolution, Part I: Supporting Clinical Processes
by JEROME CARTER on MAY 2, 2016 

No, the title is not a mistake. It simply reflects what I have come to realize over the last month or so. Innovation is about solving problems and, as the saying goes, “Necessity is the mother of invention.” Misery is a source of innovation, and the loudest cries about EHR systems with poor usability have come from primary care providers and their professional organizations. Having practiced primary care internal medicine, I understand the misery well. Primary care clinicians have been cast in the role of gatekeepers and monitors of their patients’ health, but have been given tools that mostly provide them data. The fact is clinicians are drowning in data because they do not have the tools required to make proper use of it...
Yeah. And, regarding policy, how about some contrarian Margalit Gur-Arie?
Comprehensive Primary Charade +

The most powerful persuasion tool in enlightened human society is language. The most powerful manipulation tool in any human society is language. Whereas in ancient times the pen was considered mightier than the sword, now the keyboard can be said to be mightier than any weapon of mass destruction, and nobody is mightier than the government of these United States. When our government wanted to strip citizens of privacy, it passed the Patriot act, because no one could oppose patriotism after 9/11. When it set out to facilitate corporate procurement of foreign slave labor, it enacted a set of XYZ Free Trade agreements, because this is the land of the Free. When it decided to ration health care services for the middle class, it put in place the Affordable care act, because we are all broke. Now that the U.S. government has decided to do away with the medical profession, it is feverishly rolling out Comprehensive primary care initiatives.

Comprehensive primary care is not a fuzzy, in the eye of the beholder, type of concept. Perhaps the most celebrated primary care advocate in recent times, Dr. Barbara Starfield, defined comprehensive primary care as “dealing with all health-related problems or interventions except those too uncommon to maintain competence,” where “common” means “encountered in at least one per thousand patients in a year.” The term comprehensive is an adjective intended to describe the spectrum of problems addressed in primary care without referrals to outside specialists. Comprehensive primary care is what country doctors used to provide to their patients from cradle to grave, and some still do. Comprehensive primary care is what family medicine was supposed to be all about, but it rarely is...
Interesting.
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UPDATE: ADD YET ANOTHER BOOK TO THE READING LIST

Just ran across a review of this book during my early morning requisite site-surfing -- in this case the always excellent ScienceBasedMedicine.org, "Sharks Get Cancer, Mole Rats Don’t: Clues to Understanding Cancer"

We think of cancer as caused by mutations. Mutations are necessary, but not sufficient, to cause cancer. New research indicates that it’s the body’s response to mutant cells that determines whether cancer will develop. James S. Welsh, MD, a radiation oncologist and researcher, has written a book on the immunology of cancer, Sharks Get Cancer, Mole Rats Don’t: How Animals Could Hold the Key to Unlocking Cancer Immunity in Humans. In it, he pieces together clues from animals, pregnancy, Ebola virus, infections, organ transplantation, parasites, and human cancer patients, weaving a web of insights that point to a better understanding of cancer biology and treatment.

Sharks do get cancer

The first book claiming that sharks don’t get cancer came out in 1992. It persuaded so many people to take shark cartilage that the world market exceeded $30 million and shark populations decreased by as much as 80%. Sharks do get cancer, as you can see in this picture.

Ironically, sharks can even get cancer of the cartilage! And of course shark cartilage supplements don’t prevent cancer in humans. Welsh explains how that myth got started. It was magical thinking based on extrapolation from a legitimate scientific study on angiogenesis where tumor growth in lab animals was suppressed by placing rabbit cartilage next to the tumors...
Yeah, shark cartilage, that was in the endless mix of dubious to outright bozo stuff we had to examine in the late 90's back when Sissy was ill.
...The foregoing comprise a more or less representative sampling of our experience thus far with the quackery end of the alternative therapy spectrum, a distribution of propositions whose opposite terminus abuts the breadth of mainstream clinical research and practice, where methods as yet"unproven" but more logically reasonable and promising vie for acceptance by the medical establishment. In the middle lie tougher calls: does shark cartilage really shrink tumors, functioning as an angiogenesis inhibitor? (one skeptical journal article called it "the laetrile of the 90's") Hydrazine sulfate? (also reported on extensively in the mainstream clinical literature and generally-- though not uniformly-- dismissed as 'ineffective.') Nucleotide Reductase? Plant oils? Blue-green algae?

All of these unconventional therapeutic assertions-- many of which would prove to be merely unproductive, outlandish, maddening distractions-- would have to be checked out while also slogging through the vast archives of mainstream clinical literature, a quest that would take me through the most recent three years of month-by-month National Cancer Institute (NCI) hepatoma citations. Also, I began-- and continue to this day-- keyword-searching the Medline indices for anything related to Sissy's condition that might prove useful...
More from the SBM review:
Conclusion: A great book about a terrible scourge

This is an outstanding book. It combines a fun trip to the zoo with an introductory course in cancer immunology. It’s full of weird facts that you can repeat as trivia to impress your friends. I could only sample its riches here. There is much more in the book, with details and copious references. The subject is endlessly fascinating, and the writing style is clear, appealing, and accessible, broken into 36 short, easily-digested chapters. This is cutting edge hypothesis-generating science pointing to exciting discoveries sure to come in the near future...
These people are never prone to hyperbole or taking things at face value. Once I finish the two books currently underway (scroll up), I'll have to get it and read it.

I recall the last time a ScienceBasedMedicine.org book review came to my attention, regarding Gideon Burrows' wonderful "This Book Won't Cure Your Cancer."
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More to come...

Thursday, April 28, 2016

5th Annual AARP Health Innovation@50+ LivePitch™


Well, it took me 2 hours and 12 minutes to drive the 70 miles to the Sunnyvale Plug and Play Center from my house in Antioch. I should have left the house at 5:30 instead of 6. I briefly thought about going the back way over to Livermore and then down (a lot shorter as the crow flies), but I'm glad I didn't, even though it took me an hour just to get to Walnut Creek alone on the 4 and the 242. I had KQED on the radio (as always), and they reported a major fatal crash on the 580 at Hopyard Road in Pleasanton that had westbound 4 lanes closed, with traffic backed up all the way to Altamont Pass.

Ugh. Then, I didn't get back to the house 'til about 7:45 pm after the event.

I'm glad I resisted the (coffee bladder exacerbated) episodically transient traffic gridlock urge to bail and just go back home and crawl back in the sack. The day was well worth it. Particularly in the contextual light of this book I'm close to finishing.


See also, in particular, my recent take on Dan Lyons' book "Disrupted." And, my April 25th post Digital Health IT = "Better Care at Lower Cost." Right? -- wherein I review evolutionary biologist Dan Lieberman's important book "The Story of the Human Body." As I posted over on Medium,
I could not recommend this book more highly. I would make it required reading in medical school. The genus homo has been around on earth for more than 7 million years, after branching off from its primate forbears. Roughly 99% of that time has been spent in pre-agrarian hunter-gather mode, and it is that long, ancient period to which we remain biologically adapted. To the extent we fail to take this into account, we will stymie to a significant degree everything else we try to do to improve health care and human health...
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So, this year's theme was all about "caregiving" and caregivers. Yeah, been there, done that. Between my late daughter and then my now-late parents I put in 15 years of next-of-kin caregiver duty.


Nice PDF link here.
"As of late 2014, approximately 40 million Americans provided unpaid care to an adult. This population of caregivers is estimated to reach 45 million by 2020, caring for 117 million people."
My time wearing the Driving-Miss-Sissy/POA/Legal Guardian/ADL scutwork hats was pretty much bereft of any digital apps assistance.

It looks like a lot of help is on the way. One hopes. Definitely a huge and ever-growing market. BTW, the UK's Paul Mason notes in his fine book "Postcapitalism" that there are three overlapping drivers bearing on the future of markets: [1] aging population, [2] climate change, and [3] migration. Another important read, this book.

So, this Innovation@50+ event featured, beyond the great panel discussions, short presentations by ten Pitch Competition finalists, each of whom had to then take questions from a panel of Venture Capital representatives. The audience subsequently got to vote on three (ordinal ranked) criteria as well via little hand-held remotes.
  1. "Does this product or service fill a significant need?"
  2. "Is this product or service unique?"
  3. "Would you use this product or service yourself or recommend it to family?"
The offerings spanned a wide products and services array, as did the panel and audience reactions.

At the conclusion two winners emerged, one chosen by the VC panel, one on the basis of audience vote tallies.

A few random pics from the day.


Alexandra Drane and Lisa Suennen!


Robin Farmanfarmaian.


What a story she has... I found her passing negative allusion to Theranos interesting. BTW, she has a book out.

"We are on the cusp of a healthcare revolution.

From wearable sensors, to improved point-of-care diagnostics to artificial intelligence and robotics, there are breakthroughs in biomedical technology on an almost daily basis which are set to fundamentally change the way that patients interact with their healthcare providers.

Author Robin Farmanfarmaian has seen this change first-hand. Misdiagnosed at age 16, she endured multiple surgeries and countless hospitalizations over the course of a decade before deciding to take charge of her own healthcare and changing her life overnight..."
Mo' pics...


Gonna take me a while to name all of these peeps. Difficult to take notes while shooting on the fly. I'd seen some of them at #WinterTech. Lotta smarts on the stage.

The absurdly smart 17 yr old CEO of SafeWander!
Wonder if they carded him at the 4 pm open bar reception ;)
Alex's keynote interview with AARP's Nancy LeaMond








Yeah, BobbyG loves to photograph the ladies in particular. Like, duhhh...

Competition winners Penrose (two on the L) and SingFit (two on the R)

Plug and Play is a cool place. Stage lighting sucked, though. Insufficient spots, mis-aimed, no parcan floods with gels, and no backlighting. Yeah, I'm spoiled.

I'll have further reflections shortly, but for now I'll just post the foregoing.

UPDATE
AARP Health Innovation@50+ Announces Winners of LivePitch: Penrose Senior Care Auditors as Judges’ Choice and SingFit as Consumers’ Choice
Sunnyvale, CA (PRWEB) April 28, 2016

AARP today announced the winners of its fifth Health Innovation@50+ LivePitch event held yesterday, Wednesday, April 27 at Plug and Play Tech Center in Sunnyvale, CA. Ten startup health tech companies focused on caregiving pitched their businesses and Penrose Senior Care Auditors was chosen as Judges’ Choice. SingFit was voted as Consumers’ Choice by the 400+ audience. The full event streaming video, as well as highlights, will be posted on the website which also includes more information on companies and content, at http://health50.org/.

“We were very impressed with our finalists this year, and how their businesses will improve the lives of caregivers and those they care for,” said Jody Holtzman, senior vice president, Enterprise Strategy and Innovation, AARP. “Of a great set of companies, Penrose Senior Care Auditors stood out and was recognized by our industry expert judges. SingFit resonated the most with the 400+ people who joined us yesterday. We are now excited to work with all the finalists to support their businesses as they make critical impacts in the “50 and over” health technology sector.”

Judges’ Choice Penrose Senior Care Auditors of Dallas, TX provides the first and only tech/app-enabled senior care auditing solution, called Penrose Check-Ins, to ensure seniors are okay while providing families peace-of-mind. During the Penrose Care-Check, an auditor visits the senior and using the app, assesses 150 items related to their well being and reports back to the family. @penrosecheckin

Consumers’ Choice SingFit of Los Angeles, CA combines a growing body of scientific research on the health benefits of prescribed singing with a proprietary music platform in order to mass distribute the benefits of music as medicine. Focused on dementia care and healthy aging, its debut product SingFit PRIME is the winner of the USC Keck School of Medicine Body Computing Prize. @MusicalHealthT...
I dug the SingFit thing in particular, given that I'm an ex-working musician.
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So, just prior to the conclusion of the event, Alexandra and Lisa riffed together on some really funny standup-worthy stuff about starting and VC-pitching a fake "caregiver startup" simply to prove to their loved ones that they truly cared about them.

I immediately recalled a passage in Douglas Rushkoff's book (update: which I've now finished; he saved the best for last).

INVESTMENT GAMIFIED: THE STARTUP 

When investing gets so separated from real economic activity, finding funding for a company— without falling into the growth trap— is hard. Entrepreneurs must play the same abstracted game as investors but from the other side of the board. 

One of the smartest technologists I know, a young woman from the West Coast I’ll call Ruby, decided to launch a company on a whim. She was not interested in making money or even promoting a new technology; she wanted to test her theories about how the ebbs and flows of the startup market worked and whether she could win at the game by getting herself acquired. 

So Ruby did exhaustive research on emerging interests and keywords in the technology and business press, as well as conference topics and TED subjects. What were venture capitalists getting interested in? Moreover, what sorts of technical skills would be valuable to those industries? For instance, if she concluded that big data was in ascendance, then she would not only launch a startup related to big data but also make sure she created competencies that big data firms required, such as data visualization or factor analysis. This way, even if her company’s primary offering failed, it would still be valuable as an acquisition— for either its skills or its talent, which would be in high demand if her bet on the growing sector proved correct. 

She ultimately chose geolocation services as the growing field. She assembled teams to build a few apps that depended on geolocation— less because the apps themselves were so terrific (though she wouldn’t complain if one became a hit) than because of the capabilities those apps could offer to potential acquirers. Working on them also forced her team to develop marketable competencies as well as a handful of patentable solutions in a growing field with many problems to solve. The company was purchased, for a whole lot, by a much larger technology player looking to incorporate geolocation into its software and platforms. The employees, founder, and investors who believed in her are now all wealthy people. 

Ruby is not cynical; she is a hacker by nature, and merely gamed a system that she knows is already a game. She reverse engineered a startup based on market conditions, industry trends, and nascent investor fads...
The smartest hackers understand that their skill at hacking technology may be less important than their skill at hacking the digital marketplace. To them, it’s all just code— and even if it’s not, it’s more like code every day. The economy is less a place to create value than a system to game. Hell, everyone in finance and banking is already gaming the system, extracting money from what used to be the simple capitalization of business ventures. Why not create business ventures that game the gamers at their own game?...
Rushkoff, Douglas (2016-03-01). Throwing Rocks at the Google Bus: How Growth Became the Enemy of Prosperity (pp. 184-186). Penguin Publishing Group. Kindle Edition. 
LOL. Seriously, you really need to read this one.

OFF-TOPIC ERRATUM


With apologies to Ted Cruz.
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More to come...

Tuesday, April 26, 2016

Up next, AARP Health Innovation@50+ Pitch Competition

Innovation@50+ is a one day pitch competition for emerging startups in the healthy living space with a focus on caregiving. At the pitch competition, 10 finalist companies will present their business focus on stage in a rapid 3 minute presentation to a panel of industry expert judges, most of whom are venture capitalists and angel investors focused on the aging health tech space.

Representing 38 million members, the power of AARP takes this pitch event up a notch. Only Innovation@50+ creates a dual-pitch event that also provides an audience of 100+ actual intended end user consumers who listen to the pitches and share feedback in real time, providing the companies absolutely invaluable market data on the spot.

This year’s event will be held at:
Plug and Play Tech Center
440 N. Wolfe Road
Sunnyvale, CA 94085
Should be interesting. More "VC" stuff. They've invited me to attend on a press pass. And, I'm an AARP member, Geezer-in-Training that I am, so it's of intrinsic interest.

BTW, my current book.


Yikes. Stay tuned for the review on this one. Another great read, as were my last two, cited here, and here.

For now, a little taste of Rushkoff:
...Amanda Palmer is not some monopoly company, or even a superstar performer exploiting her fans; she’s one midlist singer trying to make a living in a winner-takes-all landscape intentionally designed to prevent her from forging real relationships or exchanging value with her listeners. Her mix of barter, money, and gift is actually much more compatible with the tangled, ambiguous nature of real human relationships and hearkens back to the best qualities of the preindustrial economy.

Digital platforms from social media to crowdfunding allow us to reclaim some of these community dynamics and apply them to our own business pursuits. Those of us who have become aware of the way some corporations exploit or hide their tactics may have a knee-jerk reaction against people who appear, at least on the surface, to be doing the same thing. But the relationships that small-business people are forging with their constituencies online are direct, transparent, and peer-to-peer; they are explicit, fee-for-service, and social.

They are relationships between real people.

THE BIG DATA PLAY

The value exchange between users and social networks, or fans and giant media properties, is entirely less direct and most intentionally covert. Digital networks simulate the very same human social dynamics fueling the communities of artists like Palmer in order to generate goodwill and mass excitement for their corporate clients.

It’s a one-sided, highly controlled relationship in which, invariably, the platforms and companies with which we engage learn more about us than we ever learn about them. Social marketing creates the illusion of a natural, nonmarketed groundswell of interest and, more importantly, provides marketers with a map of social connections and influences. These social graphs, as they’re called in the industry, are the fundamental building blocks of big data companies’ analyses.

Big data is worth more than the sum of its parts. It is the technology for solving everything from terrorism to tuberculosis, as well as the purported payoff for otherwise unprofitable tech businesses, from smartphones to video games. Like pop stars, these health, entertainment, and content “plays” will make no money on their own— but the data they can glean from their users will be gold to marketers. So they hope.

Indeed, it seems as if every startup is a “big data play.” Yet when we take into account the fact that the revenue supporting big data apps must presumably come out of that same constant 5 percent of the GDP associated with marketing and advertising, it becomes clear that such a payout can’t possibly come to pass. In fact, our increasing dependence on big data solutions may actually limit the growth it’s supposed to be stoking.

Reducing people to manageable sets of numbers is nothing new to digital technology. It began long before digital spam, when the high cost of printing and mailing physical pieces of paper motivated marketers to limit their offerings to those homes that might actually be interested. They gathered publicly available data, such as tax records and mortgage information. They stored this information on physical notecards— one for each household— and then manually selected a range of cards to include in a mailing.

With the advent of computers, statisticians began categorizing people into increasingly sophisticated demographic and psychographic groups, giving rise to the first data-driven market research firms. With upwards of seventy different categories in which to put us, researchers at Acxiom, for example, could arm marketers with psychological profiles of their target audiences, helping them to match their pitches to the particular social aspirations of their customers. 32

But they soon realized that their data offered more possibilities than this: it could predict our future choices. Using more sophisticated computers and methodology, researchers began connecting seemingly unrelated data points and became capable of determining who among us was about to go to college, who was probably trying to get pregnant, and who was likely to have a particular health problem. More than merely knowing our likely receptiveness to a pitch, they became capable of calculating, with alarming accuracy, what we human beings were going to do next. They had no idea why such a prediction might be true, and didn’t really care. This was the beginning of what we now call big data.

What makes big data different from traditional market research is that it depends on correlations that make no outward human sense. That’s the truly creepy part. Privacy is the red herring. Most people are still concerned about surveillance on the actual, specific things they are doing. That’s understandable enough. So when both the NSA and corporations assure consumers that “no one is listening to your conversations” and “no one is reading your e-mail,” at least we know that our content is supposedly private. But content is the least of it. As anyone working with big data knows, the content of our phone calls and e-mails means nothing in comparison with the metadata around it. What time you make a phone call, its duration, the location from which you initiated it, the places you went while you talked, and so on, all mean much more to the computers attempting to understand who you are and what you are about to do next. Facebook can derive data from how long your cursor hovers over a particular part of a Web page. Think of how many more data points there are in that single act than there are in the price of your car or the subject of your phone call.

The more data points statisticians have about you, the more data points they have to compare with those of all the other people out there: hundreds of millions of people, each with tens of thousands of data points. Researchers don’t care what any particular data point says about you— only what it reveals when compared to the corresponding data point in everyone else’s profiles.

Combine this with the ability of the Web to keep track of individual users and you get a true one-to-one marketing solution. Instead of buying ads that every visitor to a Web site sees, advertisers can limit their ad spend to the browsers of their target consumers. It’s the same technology that lets marketers hit us with ads for products we may have recently browsed on e-commerce sites— only now, instead of using our browsing histories, they use our big data profiles.

The same sorts of data can be used to predict the probability of almost anything— from whether a voter is likely to change political parties to whether an adolescent is likely to change sexual orientation. It has nothing to do with what they say in their e-mails about politics or sex and everything to do with the seemingly innocuous data. Big data has been shown capable of predicting when a person is about to get the flu based on their changes in messaging frequency, spelling autocorrections, and movement as tracked by GPS. 33

For marketers looking for an edge, however, mere prediction isn’t enough, and this is where they tend to get in the most trouble. Big data is simply a set of probabilities. Usually, it’s hard for analysts to get more than about 80 percent certainty about a future human choice. So, for example, big data analysis may reveal that 80 percent of the people who share three particular data points are about to go on a diet. That’s a pretty good indication of where to direct their ads for diet products.

But what about the other 20 percent, who may have chosen to do something other than go on a diet? They get sent messages along with everyone else, aimed at convincing them that they need to think about their weight. Feeling fat today? If they weren’t already on the path to considering a diet, now they will be. And it’s not even human beings making the decisions about who to send which ads— it’s algorithms programmed to extract the most purchases out of consumers by exploiting their data sets. The algorithms use trial and error to see what works, iterating again and again until that 80 percent probability goes up to 90 percent. Fewer people find alternative paths as they are corralled toward the limited outcomes of their statistical profiles. Companies depending on big data must necessarily reduce the spontaneity of their customers, so that they are satisfied with what amounts to fewer available choices.

It’s a digitally complexified version of the one-size-fits-all values of industrialism.

On the surface, the increase in customers for a product looks like growth. But it’s a limited, zero-sum game, in which the reduction in new possibilities cuts both ways. Many of the companies I’ve visited have been cutting back on expensive, unpredictable research and development (R & D) and spending resources instead on big data analysis. Why ideate in an open-ended fashion, they argue, when they’ve already got the data on what consumers are going to want next quarter? It’s virtually risk free. What they don’t get is that using big data to develop new products is like looking in the rearview mirror to drive forward. All data is necessarily history. Big data doesn’t tell us what a person could do. It tells us what a person will likely do, based on the past actions of other people.

The big rub is that invention of genuinely new products, of game changers, never comes from refining our analysis of existing consumer trends but from stoking the human ingenuity of our innovators. Without an internal source of innovation, a company loses any competitive advantage over its peers. It is only as good as the data science firm it has hired— which may be the very same one that its competitors are using. In any event, everyone’s buying data from the same brokers and using essentially the same analytics techniques. The only long-term winners in this scheme are the big data firms themselves.

Paranoia just feeds the system. Becoming more suspicious of the data miners— as we do with each new leak about government spying or social media manipulation— only increases the value of data already being sold. The more restrictive we are with what we share, the more valuable it becomes and the bigger the market that can be made. We might just as easily go the other way— give away so much data that the data brokers have nothing left to sell. At least that would put them all in the same boat as the rest of us.

Rushkoff, Douglas (2016-03-01). Throwing Rocks at the Google Bus: How Growth Became the Enemy of Prosperity (pp. 39-44). Penguin Publishing Group. Kindle Edition.
You need to read this book as well.
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More to come...

Monday, April 25, 2016

Digital Health IT = "Better Care at Lower Cost." Right?

That was the promise, recall?


Below, I shot this off a slide deck screen at the HIMSS Conference in 2012.


Last Friday while on my way home from my Muttville.org weekly volunteer day in San Francisco, I heard an interesting NPR "Intelligence Squared" debate on the question "should corporate subsidies be eliminated?"
ABOUT THIS EVENT
The auto industry, agriculture, the energy sector. What do they have in common? These industries benefit from government subsidies in the form of loans, tax breaks, regulation, and other preferences. Critics from the left and right say that not only do these subsidies transfer wealth from taxpayers to corporations, they distort the markets and our economy. Proponents say that government has an important role to play in launching innovation via strategic investment, and its support helps American companies thrive. Do we need subsidies, or is this corporate welfare?
From the transcript:
[applause]

And that motion is Eliminate Corporate Subsidies and here to make his closing statement against the motion, Michael Lind, policy director of the economic growth program at New America and author of "Land of Promise."

Michael Lind:
Medical errors are the third leading cause of death in the United States. Up to 440,000 Americans die each year from preventable medical errors. A lot of it because the lag with doctor's offices using paper records. As part of the stimulus act in 2009, the federal government has spent to date more than $35 billion in incentives to individual doctors, hospitals, and other health care providers. What's the result? In 2009, those using -- the physicians using electronic health records were only 21.8 percent. Today, a few years later, they are 78 percent. The subsidy worked. In 2009, only 12.2 percent of non-federal acute care hospitals were using a basic computer electronic health record system. By 2014, after this $30 billion had been spent, more than 76 percent were. This is a tremendous unsung success of federal policy. Now, there are problems with the next stage.

There are problems with interoperability, with monopolistic corporations engaged in so- called data blocking. So there are problems with it. But, you know, this sort of really brings it home. As a result of this particular highly successful federal subsidy, your loved ones or your own life may be saved and as long as there are a few programs like this that are successes, you need to vote against the motion.

John Donvan:
Thank you, Michael Lind.

[applause]
Well, myriad critics would dispute the assertion that the HITECH "Meaningful Use" initiative has turned out to be a "highly successful federal subsidy." Mr. Lind's citing of post-MU accelerated HIT uptake does nothing to answer the "better care at lower cost" question. Many critics argue that MU has in fact stifled innovation, and has largely served to line the pockets the large incumbent EHR vendors, while perhaps even having an adverse effect on care delivery, via clinically irrelevant "productivity treadmill" compliance imperatives.

Beyond issues of uniform, appropriate operational definitions of "better" and "lower cost," I continue to regard it as premature to declare either "failure" or "victory" in this area. As I observed a year ago in my March 2015 HITECH Interoperababble Update post:

I have noted before what I call "Health IT Policy ADHD." Major legislation gets passed and funded, and when we don't get immediate, dazzling results, we go sour on it, lamenting its "failure," and calling for its demise. HITECH is not that old. There have really only been four years of full-bore boots-on-the-ground operation. REC contracts were let in 2010, and the RECs spent most of their first year getting their sea legs under them and scurrying about hustling skeptical clinical participants...

We never tire of citing the "information superhighway" analogy. Fine. The U.S. Interstate Highway system took more than 35 years to complete. Significantly and sustainably transforming the incredibly complex, heterogeneous U.S. healthcare delivery and information infrastructure easily rivals it in scale and exceeds it in complexity by orders of magnitude. Moreover, this $35 billion outlay comes to about $22 per capita per year since the deployment of the HITECH program five years ago. The latest NHE per capita expenditure is about $10k. $22 is about 0.2% of that (0.0022). Close to being a rounding error...
Some other vexingly inhibitory factors go to the byzantine, dysfunctional economic imperatives of organizational structures and cultures in the health care space. See my accruing rant The U.S. healthcare "system" in one word: "shards."

On healthcare workforce cultural dysfunction specifically, recall my post The "Talking Stick" and the three-legged stool of sustained, transformative healthcare QI.

Socioeconomic issues: “When it comes to health, your zip code matters more than your genetic code.”

Relatedly, The future of health care, continued. Where will economics come in?

Then, there are more fundamental concerns, going to the effects of digitization on clinical cognition per se. See Are structured data now the enemy of health care quality?

I've also set forth my concerns regarding "personalized medicine," which necessarily include the various "omics" scientific disciplines. See, e.g., Omics update: National Human Genome Research Institute Health IT news.

So many contending, frequently mutually-negating moving parts, so little time.

Now comes a very big new wrinkle.


This book has been an utter delight to read, at once scholarly, scientific, accessible, and conversationally genial. The implications for health and health care delivery could not be more important, IMO. Seems like I spent half of the weekend reading parts of it aloud to my wife. I bought the Kindle edition, and have also just ordered a hardcopy for her and my daughter.
PREFACE
...I have made the human body the focus of my career. In fact, I am extremely lucky to be a professor at Harvard University, where I teach and study how and why the human body is the way it is ... I study fossils, I travel to interesting corners of the earth to see how people use their bodies, and I do experiments in the lab on how human and animal bodies work...

...of all the questions I am commonly asked, the one I used to dread the most was “What will human beings look like in the future?” ... My reflexive answer was always something along the lines of: “Human beings aren’t evolving very much because of culture.” This response is a variant of the standard answer that many of my colleagues give when asked the same question.

I have since changed my mind about this question and now consider the human body’s future to be one of the most important issues we can think about. We live in paradoxical times for our bodies. On the one hand, this era is probably the healthiest in human history. If you live in a developed country, you can reasonably expect all your offspring to survive childhood, to live to their dotage, and to become parents and grandparents. We have conquered or quelled many diseases that used to kill people in droves: smallpox, measles, polio, and the plague. People are taller, and formerly life-threatening conditions like appendicitis, dysentery, a broken leg, or anemia are easily remedied. To be sure, there is still too much malnutrition and disease in some countries, but these evils are often the result of bad government and social inequality, not a lack of food or medical know-how.

On the other hand, we could be doing better, much better. A wave of obesity and chronic, preventable illnesses and disabilities is sweeping across the globe. These preventable diseases include certain cancers, type 2 On the other hand, we could be doing better, much better. A wave of obesity and chronic, preventable illnesses and disabilities is sweeping across the globe. These preventable diseases include certain cancers, type 2 diabetes, osteoporosis, heart disease, strokes, kidney disease, some allergies, dementia, depression, anxiety, insomnia, and other illnesses. Billions of people are also suffering from ailments like lower back pain, fallen arches, plantar fasciitis, myopia, arthritis, constipation, acid reflux, and irritable bowel syndrome. Some of these troubles are ancient, but many are novel or have recently exploded in prevalence and intensity. To some extent, these diseases are on the rise because people are living longer, but most of them are showing up in middle-aged people. This epidemiological transition is causing not just misery but also economic woe. As baby boomers retire, their chronic illnesses are straining health-care systems and stifling economies. Moreover, the image in the crystal ball looks bad because these diseases are also growing in prevalence as development spreads across the planet.

The health challenges we face are causing an intense worldwide conversation among parents, doctors, patients, politicians, journalists, researchers, and others. Much of the focus has been on obesity. Why are people getting fatter? How do we lose weight and change our diets? How do we prevent our children from becoming overweight? How can we encourage them to exercise? Because of the urgent necessity to help people who are sick, there is also an intense focus on devising new cures for increasingly common noninfectious diseases. How do we treat and cure cancer, heart disease, diabetes, osteoporosis, and the other illnesses most likely to kill us and the people we love?

As doctors, patients, researchers, and parents debate and investigate these questions, I suspect that few of them cast their thoughts back to the ancient forests of Africa, where our ancestors diverged from the apes and stood upright. They rarely think about Lucy or Neanderthals, and if they do consider evolution it is usually to acknowledge the obvious fact that we used to be cavemen (whatever that means), which perhaps implies that our bodies are not well adapted to modern lifestyles. A patient with a heart attack needs immediate medical care, not a lesson in human evolution.

If I ever suffer a heart attack, I too want my doctor to focus on the exigencies of my care rather than on human evolution. This book, however, argues that our society’s general failure to think about human evolution is a major reason we fail to prevent preventable diseases. Our bodies have a story— an evolutionary story— that matters intensely. For one, evolution explains why our bodies are the way they are, and thus yields clues on how to avoid getting sick. Why are we so liable to become fat? Why do we sometimes choke on our food? Why do we have arches in our feet that flatten? Why do we have backs that ache? A related reason to consider the human body’s evolutionary story is to help understand what our bodies are and are not adapted for. The answers to this question are tricky and unintuitive but have profound implications for making sense of what promotes health and disease and for comprehending why our bodies sometimes naturally make us sick. Finally, I think the most pressing reason to study the human body’s story is that it isn’t over. We are still evolving. Right now, however, the most potent form of evolution is not biological evolution of the sort described by Darwin, but cultural evolution, in which we develop and pass on new ideas and behaviors to our children, friends, and others. Some of these novel behaviors, especially the foods we eat and the activities we do (or don’t do), make us sick...

The core subjects of this book— human evolution, health, and disease— are enormous and complex. I have done my best to try to keep the facts, explanations, and arguments simple and clear without dumbing them down or avoiding essential issues, especially for serious diseases such as breast cancer and diabetes...

...I have rashly concluded the book with my thoughts about how to apply the lessons of the human body’s past story to its future. I’ll spill the beans right now and summarize the core of my argument. We didn’t evolve to be healthy, but instead we were selected to have as many offspring as possible under diverse, challenging conditions. As a consequence, we never evolved to make rational choices about what to eat or how to exercise in conditions of abundance and comfort. What’s more, interactions between the bodies we inherited, the environments we create, and the decisions we sometimes make have set in motion an insidious feedback loop. We get sick from chronic diseases by doing what we evolved to do but under conditions for which our bodies are poorly adapted, and we then pass on those same conditions to our children, who also then get sick. If we wish to halt this vicious circle then we need to figure out how to respectfully and sensibly nudge, push, and sometimes oblige ourselves to eat foods that promote health and to be more physically active. That, too, is what we evolved to do.


Lieberman, Daniel (2013-10-01). The Story of the Human Body: Evolution, Health, and Disease. Knopf Doubleday Publishing Group. Kindle Edition, locations 41-99.
Boy, does he ever deliver across the full span of the book. A must-read, in my view.

Some triangulation.


I came to this book by way of ScienceBasedMedicine.org, one of my requisite daily stops.
Human life has changed immensely over the millennia, but never so much or so quickly as in the past century. For almost the entire 200,000-year existence of our species, Homo sapiens, biology controlled us. We gathered fruits, nuts, and plants; hunted and fished for the animals that were available; and like the wildebeest or zebra, we moved on when resources ran low. Even after the advent of farming and civilization, and the development of cities, we were still very vulnerable to the whims of the weather, and to famine and epidemics. 

But in just the past hundred years or so, we have turned the tables and taken control of biology. Smallpox, a virus that killed as many as 300 million people in the first part of the twentieth century (far more than in all wars combined) has not merely been tamed but has been eradicated from the planet. Tuberculosis, caused by a bacterium that infected 70– 90 percent of all urban residents in the nineteenth century and killed perhaps one in seven Americans, has nearly vanished from the developed world. More than two dozen other vaccines now prevent diseases that once infected, crippled, or killed millions, including polio, measles, and pertussis. Deadly diseases that did not exist in the nineteenth century, such as HIV/ AIDS, have been stopped in their tracks by designer drugs. 

Food production has been as radically transformed as medicine. While a Roman farmer would have recognized the implements on an American farm in 1900— the plow, hoe, harrow, and rake— he would not be able to fathom the revolution that subsequently transpired. In the course of just one hundred years, an average yield of corn more than quadrupled from about 32 to 145 bushels per acre. Similar gains occurred for wheat, rice, peanuts, potatoes, and other crops. Driven by biology, with the advent of new crop varieties, new livestock breeds, insecticides, herbicides, antibiotics, hormones, fertilizers, and mechanization, the same amount of farmland now feeds a population that is four times larger, but that is accomplished by less than 2 percent of the national labor force compared to more than 40 percent a century ago. 

The combined effects of the past century’s advances in medicine and agriculture on human biology are enormous: the human population exploded from fewer than 2 billion to more than 7 billion people today. While it took 200,000 years for the human population to reach 1 billion (in 1804), we are now adding another billion people every twelve to fourteen years. And, whereas American men and women born in 1900 had a life expectancy of about forty-six and forty-eight years, respectively, those born in 2000 have expectancies of about seventy-four and eighty years. Compared to rates of change in nature, those greater than 50 percent increases in such a short timespan are astounding...

Diseases, it turns out, are mostly abnormalities of regulation, where too little or too much of something is made. For example, when the pancreas produces too little insulin, the result is diabetes, or when the bloodstream contains too much “bad” cholesterol, the result can be atherosclerosis and heart attacks. And when cells escape the controls that normally limit their multiplication and number, cancer may form. 
To intervene in a disease, we need to know the “rules” of regulation...

Carroll, Sean B. (2016-02-16). The Serengeti Rules: The Quest to Discover How Life Works and Why It Matters (Kindle Locations 96-130). Princeton University Press. Kindle Edition.
"To intervene in a disease, we need to know the “rules” of regulation."

Yeah, and Dr. Lieberman would say that we need to look more closely at the implications of the broad span of human evolution in order to effectively manage, mitigate, and/or cure what he calls today's "diseases of evolutionary mismatch." Absent that contextual grounding, we may well do everything else (including HIT deployment and process QI) as efficaciously as possible and still come up short.

BTW, tangentially, a bit more "evolution" triangulation.


Michael Tomasello sets forth a pretty compelling case for the evolutionary adaptive utility of prosocial, empathic, and altruistic inclinations and behaviors. My summary excerpts here.

Ayn Randians will have a cow.

Dr. Lieberman:
...For millions of years, our ancestors relied on innovation and cooperation to get enough food, to help care for one another’s children, and to survive in hostile environments, such as deserts, tundras, and jungles. Today we need to innovate and cooperate in new ways to avoid eating too much food, especially excess sugar and processed industrial foods, and to survive in cities, suburbs, and other unnatural environments. We therefore need government and other social institutions on our side, because we never evolved to choose healthy lifestyles. Most people don’t get sick through any fault of their own, but instead they acquire chronic illnesses as they age because they grew up in an environment that encourages, entices, and sometimes even forces them to become sick. For many of these diseases, we can then only treat the symptoms. Unless we want to end up as a species ever more dependent on medicines and expensive technologies to cope with the symptoms of preventable diseases, we need to change our environments. In fact, it is questionable whether we can continue to afford the cost of our current trajectory of increased longevity and population sizes combined with increased chronic morbidity. 

I think it is reasonable to conclude that cultural evolutionary processes today are gradually replacing one form of coercion with another. For millions of years, our ancestors were required to consume a naturally healthy diet and to be physically active. Cultural evolution, especially since humans began farming, has transformed how our bodies interact with the environment. Many people today still live in poverty and suffer from diseases caused by poor sanitation, contagion, and malnutrition that were much less common in the Paleolithic. Those of us fortunate enough to live in the developed world have escaped those miseries, and we can now choose to be inactive as much as we want and eat whatever we crave. In fact, for some, such habits are the default setting. Those choices or urges, however, often make us sick in other ways, which then compel us to treat our symptoms. Right now, we are generally satisfied with the system we have created, thanks to long life spans and overall decent health. But we could do better. And as the mismatch environments we have created and pass on to our children through the pernicious feedback loop of dysevolution intensify, we increase our risk of suffering from needless, preventable diseases. [Lieberman, op cit, pp. 364-365].
I would make Daniel Lieberman's book required reading in Med School. Buy it and study it ASAP.

BTW, I came to the book here, at The Daily Beast.

CODA


Count me a fan of Gould's "Drunkard's Walk" theory of evolution.
Before the advent of rapid, accurate, and inexpensive DNA sequencing technology in the early 2000s, biologists guessed that genes would provide more evidence for increasing complexity in evolution. Simple, early organisms would have fewer genes than complex ones, they predicted, just as a blueprint of Dorothy’s cottage in Kansas would be less complicated than one for the Emerald City. Instead, their assumptions of increasing complexity began to fall apart. First to go was an easy definition of how complexity manifested itself. After all, amoebas had huge genomes. Now, DNA analyses are rearranging evolutionary trees, suggesting that the arrow scientists envisioned between simplicity and complexity actually spins like a weather vane caught in a tornado...

With comb jellies at the base of the tree, evolution suddenly seems less like a march towards complexity and more like a meandering stroll. This isn’t a new idea. Back in 1996, evolutionary biologist Stephen Jay Gould posited that evolution progresses like a drunkard’s walk. Organisms, he said, stand an equal chance of becoming simpler or more complex over millions of years—although sometimes there’s a lower limit on how simple they can possibly be, just as a drunk may fall into a gutter at the far left side of the road. An Internet meme even celebrates oddities that result from evolution’s stumble: “ Go Home Evolution, You’re Drunk,” features organisms with sub-optimal traits that have managed to survive just fine...

Perhaps the fact that people are stunned whenever organisms become simpler says more about how the human mind organizes the world than about evolutionary processes. People are more comfortable envisioning increasing complexity through time instead of reversals or stasis. Physicist Sean Carroll calls humans “ terrible temporal chauvinists” for this reason, because they desperately want the street from the past to the future to run in one direction. The textbook scenarios on early animal evolution might be correct, but they should be treated as hypotheses built by temporal chauvinists. When new data suggests a rearrangement, it must be considered no matter how perplexing the conclusion seems.

Casey Dunn, an evolutionary biologist at Brown University in Providence, R.I. who took part in the still-contentious comb jelly project, now doubts all notions of increasing complexity. Instead, he says the environment selects whatever form handles the challenges at hand, be it simple, complex, or plain ugly.  Mother Nature, with her 4 billion years of experience, does not work like Steve Jobs, continuously designing sleeker versions. When asked whether de-evolution, a reversal from the complex to the simple, happens frequently, Dunn replies, sure. “But,” he adds, “I wouldn’t call that de-evolution, I’d call it evolution.”
The "bush of life" rather than "the tree of life" metaphor. I just like the "Occam's Razor" simplicity as it applies to evolution. You need assume only three things, all of which exist: [1] simple carbon-based organisms capable of reproducing, [2] a relatively stable environment with a reliable source of energy input, and [3] a lot of time. You need not anthropomorphically assume "purpose," "intentionality," an evolutionary "drive toward complexity."

Pop the clutch, and 4.7 billion years later you might end up with us (along with the enormous volume of single-celled microbial life that still accounts for the bulk of planetary biota). Re-run the experiment and you probably get something unrecognizably different (Dr. Lieberman even generally alludes to this likelihood).

All the more reason to treat life with reverence.

PS-

Put up a short post, one pointing back here, over at the new Medium.com publishing platform. See The underappreciated evolutionary factors that bear on human health and impede effective modern health care

Just trying out the Medium.com platform. It's OK. I have my doubts as to their business model.
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More to come...