Tuesday, October 18, 2016

"Treat the numbers instead of the patient?"

My daily morning online surfing rounds always include the excellent STATnews, where this caught my eye:
Improving health care with the simple act of listening
Vikas Saini, MD
...In medical school, doctors-in-training are taught that 85 percent of a diagnosis comes from a careful history, and another small portion comes from the physical exam. But these days we are so busy testing that it’s easy to miss the subtle — and sometimes not so subtle — indicators of a patient’s health. It’s certainly quicker to order the test, get some numbers, and then treat the numbers instead of the patient.

The doctor-patient visit is becoming a commodified transaction rather than a collaboration. Clinical life feels more and more like sprinting on a hamster wheel, chasing unproven metrics to get graded on “quality.” It’s no wonder that burnout is exploding among physicians across the country.

The idea that more is better has many Americans going from doctor to doctor to doctor, getting test after test, and becoming increasingly anxious about our health while increasing the cost of health care.

We’ve been told that a big problem with health care is inefficiency and waste. (It is.) We’ve been told that old fashioned doctoring results in huge variations of care. (It does.) We’ve been told that constant electronic nudging will make doctors better. (Maybe.) Doctors are being told they must make their productivity numbers to keep their jobs and prove they are efficient. (Sad but true.)

Pioneering cardiologist and Nobel Peace Prize winner Dr. Bernard Lown has said that the usual rules of efficiency are inverted in medicine. The more time a physician spends with patients, the more efficient he or she becomes. Listening costs next to nothing, and so is infinitely more cost-effective than drugs and devices. Listening promotes healing and causes no harm. In fact, it’s the bedrock of a genuine trusting relationship — something everyone wants from their doctors and nurses. In the tone of voice, in the subtlety of the pattern of pain, in getting the sequence of events right — that’s how a correct diagnosis is made and the person emerges from the patient. If all health care providers listened better, we would save billions of dollars and transform the system. So why don’t we have the time we need to listen?

Because clinicians have been put on a treadmill driven by the pitiless demands of a false concept of efficiency. Money has replaced quality care as the measure of health care. The idolatry of the market is driving a race among hospitals, insurers, and manufacturers to get bigger and bigger.

To fix health care, we need a genuine democratic dialog. To start that, our society needs a massive dose of listening to understand what really matters to patients and communities...
"It’s certainly quicker to order the test, get some numbers, and then treat the numbers instead of the patient."

Goes materially to the central debate surrounding Health IT. Useful here to revisit my prior post "Are structured data the enemy of health care quality?" As I wrote there:
Perhaps optimal "health care quality" requires the open-ended analytical narrative in the progress note, replete with evocative, dx-illuminating metaphors and analogies and elegant turns of phrase in lieu of blunt instrument categorical and ordinal "structured data." That whole elusive "Art of Medicine" thing. The "Spaces Between the Facts comprising 'Big Data'." The slow, contemplative Medicine of "God's Hotel." Listen. look, palpate, empathize...
See also my earlier post "Clinician "burnout." Is HIT a significant factor?"

Another requisite daily stop of mine is "The Incidental Economist: The health services research blog."
Why is improvement in the quality of health care so slow?

In JAMA Internal Medicine, David Levine, Jeffrey Linder, and Bruce Landon look at progress in improving quality of care in the US since 2002. They are not impressed...

I strongly agree that:
  • Measurement in and of itself does little,
  • Incentives won’t always change behaviour, particularly if the cost of change outweighs the value of the incentive, and
  • Quality improvement is accomplished by “health professionals on the front lines in collaboration with their patients.”
But I don’t think these points quite capture why it’s so hard to improve medical quality. I see two reasons why we might have expected change to be faster. First, we expected change to be fast because we looked at dramatic improvements in quality achieved in other industries, such as automobile manufacturing.  Second, other nations deliver care that looks at least as good (or better) than US care, at significantly lower cost. This makes it seem like that there should be low-hanging fruit to harvest, that is, we should be able to make quick changes that move us to a higher quality of care without increasing cost.

Change is hard, in my view, because the fruit is harder to pick than we thought. The fruit is hard to pick in part because delivering health care is not much like making a car...
"...delivering health care is not much like making a car."

Yeah. A standard complaint, that one. Neither is it like aviation, as many QI-skeptic docs grouse. "We're different," goes the common grumpy retort. "Stick your Toyota Production System and pilot checklists where the sun don't shine..."
Auto manufacturing involves highly standardized and intensively automated workflows. Changing how work gets done may require a lot of capital investment. Nevertheless, a numerically-controlled lathe will change what it does when you reprogram it. And you don’t need to worry about the expectations of the steel that the lathe shapes. Medical work is much less standardized. No two patients are the same, biologically, psychologically, or in their social circumstances. Unlike steel, patients have agency that the care system should and must accommodate. All this makes caregiving a matter of craft skills, and care ‘algorithms’ are often more like suggestions. Above all, because they are craftsmen and craftswomen, and not robots, caregivers can be nudged, but they can’t be programmed...

My hope is that the problem is that improvement in the quality of health care is slow because we are still on the left hand side of the [logistic S] curve, and change will speed up in the future. Or, perhaps, we will eventually figure out how medical care can be automated.
"Or, perhaps, we will eventually figure out how medical care can be automated."

Lordy. Recall my earlier post "The future of health care? "Flawlessly run by AI-enabled robots, and 'essentially' free?"


also apropos of "health care quality." Yet another daily stop, Science Based Medicine. Just ran into citation of this book.

Downloaded. Just as I'm finishing up Robert Cialdini's intriguing "Pre-suasion." Dr. Rawlins' book also goes to "waste" and "poor quality" in health care. I'm instantly reminded of all the absurd crap I had to wade through during my daughter's terminal cancer illness.

Also on deck, relatedly, some other stuff I'm looking at.

LOL. e.g., as reported by Eric Pfeiffer:
...Self-help is a $10 billion industry. People are hungry to form new habits; it’s the age of behavioral psychology meets the productivity zeitgeist, and whether your techniques are peer-reviewed or merely placebo, they’re certainly sellable. (Amen’s take on what counts as “tested”: “The best way to evaluate these techniques is to try simple things and measure where you notice improvement.”) [Jim] Kwik often fields personal questions from his audiences, offering what he calls a “personal trainer for your brain.” Soft-spoken and geeky, he conducts his webinars in front of a giant Iron Man mural while wearing a T-shirt with a picture of a brain over the tagline, “There is no app for that.” His online classes and seminars run around $400; some clients pay upward of $10,000 per person for in-person coaching, either one-on-one or in small groups... ["Is Jim Kwik the Next Lumosity or Just the Next Fad?"]

I got an email from Robin Farmanfarmaian the other day.
Dear Friends,

My friend Jim Kwik is hosting a gathering I wish the entire world could attend: the Superhero Brain Summit.

It will be one of the best events of the year, completely dedicated to optimizing the supercomputer between our ears that controls everything from your health to happiness and influence to income.

Jim usually charges $2,000 for a ticket to attend this...

But since I was a speaker, I can invite my network to get free online insider access today.

Inside you'll get access to topics including memory improvement, speed-reading, optimal brain diet, creativity, mindfulness, work productivity, sleep, and more.

Reserve your spot to attend this Superhero Brain training

If you don’t know Jim, his clients include the likes of Elon Musk to entertainers like Will Smith as well as other top entrepreneurs and entertainers.

Jim has arranged one of the most amazing lineup of speakers:

Dr. Mark Hyman, 10x New York Times Bestselling Author. Director of the Cleveland Clinic Center for Functional Medicine. Superpower of ULTRA-MIND.

Dr. Daniel & Tana Amen, New York Times Bestselling Authors. Creators of the Amen Clinics, the leader in brain optimization. Superpower of BRAIN HEALTH.

Jim Kwik, Founder of Kwik Learning. Superpower of MEMORY & SPEED-READING.

Dave Asprey, New York Times Bestselling Author. Founder of Bulletproof Coffee. Superpower of BRAIN BIOHACKS.

Shannon Lee, Daughter of Bruce Lee, shares her father’s approach to deep learning. Superpower of MASTERY.

Jack Canfield, Co-Author of the Chicken Soup for the Soul series with one billion books in print. Superpower of FOCUSED MINDSET.

Shawn Stevenson, Nutrition Expert. Bestselling Author. Superpower of SLEEP.

Keith Ferrazzi, New York Times Bestselling Author and world’s foremost expert on professional relationship development. Superpower of CONNECTION.

And tons more!
Here's the video clip embedded in Robin's email.

"I build better brains." (@0.33)

Science, or showbiz/marketing hyperbole?

"Brain optimization." Been pondering the brain a good bit of late (mostly, but not exclusively, in the context of considering the implications for "AI"). See my post "The locus of Mind."

We shall see. My first reaction to Robin's email was "I'm havin' a Landmark Forum Moment." I went to one of those last year, invited by a friend.
The profitable field Landmark helped pioneer is now crowded with life coaches, time-management gurus, and productivity bloggers. Like David Allen's Getting Things Done or Stephen Covey's The 7 Habits of Highly Effective People, Landmark is just one of dozens of quasi-philosophies that promise to empty your inbox and fulfill your personal goals. And maybe survive the recession. Since the Great Depression, when Dale Carnegie's seminars on how to win friends and influence people became popular, the personal development industry has bloomed under darkening economic skies. Forget work/life balance; that's so 2008. How to do more in less time is today's hot productivity trend. (Landmark's website touts a survey in which one-third of Forum grads reported that their incomes rose at least 25 percent after participating; 94 percent of those attributed it to the program.) Yet if Landmark is just another outpost in lifehacking country, why does it seem so insidious?

Part of it is the in-your-face, hard-sell ethos embedded in the corporate DNA it inherited from est. Forum grads are urged to stay involved and "invite" friends and family. After finishing the Forum, I received calls asking me to volunteer at the Landmark call center and come in for one-on-one coaching. The company also vigorously guards its reputation from critics. After I told Beroset I'd be writing an article on my mixed feelings about the Forum, she called several times and sent me an email that might be described as threatening—but in the most benign, centered kind of way...
I found it creepy. Scientifically bogus, and, yes, irritatingly evangelistically hard-sell.

I first encountered Robin Farmanfarmaian during the "5th Annual AARP Health Innovation@50+ LivePitch" event. Bought and read her book (note: she appears onstage very briefly in the above promo video at 2:14).

So, after getting her pitch email. I started doing a bit a digging. Stay tuned. Is this stuff also "For Entertainment Purposes Only?"

More Eric Pfeiffer:
Kwik, like many of his brethren in the new generation of self-help, is no doctor. Rather, his stuff falls more in the realm of personal-management gurus like Tim Ferriss and Brendon Burchard, who themselves are modern-day versions of Tony Robbins. But he’s playing in a space full of people purporting to have real impact on your neurons: His competitors are companies like Lumosity, which provides brain games to keep you sharp, and which neuroscientists have spoken out against.

“It is 100 percent possible to use scientific methods to verify whether these programs improve memory and reading,” says Elliot Berkman, a neuroscientist and assistant professor in the University of Oregon’s department of psychology. All Kwik or Lumosity would need to do is conduct a controlled experiment. “As far as I can tell,” Berkman says, “neither Kwik nor Lumosity has done this.” Kwik is used to the criticism and says that all of his techniques are based on pre-existing methods backed by scientific studies. He says his role is more messenger than creator...
[Kwik] "says that all of his techniques are based on pre-existing methods backed by scientific studies."

Well, I've only begun searching, but thus far all I'm seeing on his many shiny websites are numerous breathless testimonials.

"Jim Kwik is a world expert in speed-reading, memory enhancement, and optimal brain performance."

"World expert," 'eh? In the following?
Neuroscience is the scientific study of the nervous system. Traditionally, neuroscience is recognized as a branch of biology. However, it is currently an interdisciplinary science that collaborates with other fields such as chemistry, cognitive science, computer science, engineering, linguistics, mathematics, medicine (including neurology), genetics, and allied disciplines including philosophy, physics, and psychology. It also exerts influence on other fields, such as neuroeducation, neuroethics, and neurolaw. The term neurobiology is often used interchangeably with the term neuroscience, although the former refers specifically to the biology of the nervous system, whereas the latter refers to the entire science of the nervous system, including elements of psychology as well as the purely physical sciences.

The scope of neuroscience has broadened to include different approaches used to study the molecular, cellular, developmental, structural, functional, evolutionary, computational, and medical aspects of the nervous system. The techniques used by neuroscientists have also expanded enormously, from molecular and cellular studies of individual nerve cells to imaging of sensory and motor tasks in the brain. Recent theoretical advances in neuroscience have also been aided by the study of neural networks...
I'm still looking for a CV and/or a list of Jim Kwik books and other publications. Zilch thus far.

On "testimonials." From Dr. Rawlins' book cited above:
Secret 10. Communal reinforcement 
As Robert Carroll suggests in The Skeptic’s Dictionary, CAM practitioners network and those in the network feed off each other’s enthusiasm in a climate of mutual support. So of course do conventional practitioners. Camists may come to believe each other’s hype and that they have ‘the secret, the powers, the gift’. They note each other’s patient testimonials of benefit – the CAM ‘worked’. The camist feels revitalised and empowered. Testimonials are not followed up to check that what may be a patient’s temporary lift in mood due to expectation actually lasts. The regressive fallacy is overlooked. There is no monitoring of patients who do not return to the camist and may not have benefitted. There is no credible scientific evidence. Camists are complacent about this lack of attention to detail, but given others in the network who accept this stance, the community simply reinforces its faith.

Rawlins, Richard (2016-05-15). Real Secrets of Alternative Medicine: An Exposé (pp. 281-282). Placedo Publishing. Kindle Edition.
I've reached out to Dr. Berkman for reaction and comment.

A couple of quick observations:
  1. What would comprise "scientific methods to verify whether these programs improve memory and reading." Well, it would be difficult, and rather expensive just getting a methodologically defensible (adequately sized and stratified) baseline against which to run a proper "clinical trial" (wherein "improve" is accorded an outset operational definition).
  2. I take issue with the framing. What truly should count is effective analytical critical thinking, not simply reading speed and memory. Whipping through reams of text and subsequently being able to better recall "facts" is only part of the story. Being able to adequately evaluate arguments is what matters in the end (when I was a kid in school back before indoor plumbing, much of this was simply known as "reading comprehension").

    Unless, of course, your goal is simply being entertained. Nothing wrong with that, I guess. It's your money. But, let's not infer that it's summarily "neuroscience" that will improve your health and your life.
Regarding point 2 above, on "evaluating arguments": Most real-world arguments of any social significance are maddeningly complex and fraught with opacity and contradiction, requiring Kahneman's "Slow Thinking." My first grad school semester paper comprised an analytical deconstruction and evaluation of the 1994 JAMA Single Payer proposal (pdf). It was ploddingly deliberative, involving accurately flow-charting and then assessing every individual "premise-conclusion" claim leading to the final proffer. I have at least a good hundred hours in that effort.

Would speed reading and memory improvement training have helped, net? I rather doubt it.


Recall my snarky tweet above?

It is increasingly fashionable to cavalierly toss around "neuro"-this and "neuro"-that amid the digerati / Silicon Valley hype-fest. Come up with some smartphone app called "NeuroYoga" or "NeuroQigong" and you can probably land a 7-figure Seed Round (while you sip on some "NeuroBliss" juice). I may have to add the word "neurobabble" to my list of dubiety -- e.g., "interoperababble" (and, "omics-o-babble" may soon be a candidate as well).

OK, how about this app, which I've cited before?

Again, NeuroTrainer is the startup founded by my niece's husband Jeff Nyquist. A core claim of therapeutic benefit they proffer is that of "collision sports" concussion risk mitigation and remediation, via gamified VR visual acuity training. Jeff's 2007 Vanderbilt "neuropsychology" doctoral dissertation, Perceptual Training Yields Rapid Improvements in Visually Impaired Youth, established much of the scientific grounding (9 pages of citations at the end). Several subsequent Nyquist et al publications have built on the work, e.g., Peripheral Vision of Youths with Low Vision: Motion Perception, Crowding, and Visual Search (2012). The latter paper contains two concluding pages comprising 55 scholarly citations. 

I first made note of NeuroTrainer back in January while covering the Health 2.0 "WinterTech" Conference. From that post:
Jeff holds a PhD in Neuropsychology from Vanderbilt. A principal initial focus of his technology is brain injury mitigation within the collision sports (e.g., football, hockey, soccer) via virtual reality-based neural training, specifically occipital lobe visual cortex enhancement -- technology historically rooted in part in the naval combat air "Top Gun School" peripheral vision acuity methods.
April emailed the other day to let me know that some of Jeff's work is on deck to be published in Nature.com's publication "Scientific Reports."

Obviously, I hope they will be successful. If they are, I am comfortable that the success, beyond factors of market timing, savvy marketing and sales, and adroit company management, will in large measure owe of the underlying science of the technology.
In fairness, I would not expect Jeff (or other digitech startup entrepreneurs) to publish their proprietary intellectual property "secret sauce," although, as we have recently learned via the sad Theranos Silicon Valley multibillion dollar CusterFluck, independently confirmable foundational science transparency goes to credibility -- and, success, long-term.
In sum, when I see hyperbolic claims such as Mr. Kwik's buttressed mainly by glitzy websites and twitter pages festooned with photos of the rich and famous (along with their myriad superlatives-laden testimonials, and the concomitant arrays of corporate logos), I reflexively just skeptically have to ask "what's the evidence, the science?"

Go to one of the Kwik sites, and you are promptly hit with this popup:

Love the "No thanks. I like being just an average human."

A bit condescending, that. That's supposed to give me the warm fuzzies?

"I build better brains."

OK. Prove it. "In God we trust. All others bring data."

I have no doubt that Mr. Kwik is a delightful person, one with a heartrending personal story of struggle and surmount. Not the issue. You don't get a pass just because you're in the chirpy, well-meaning consumer-facing "wellness"/ self-help market. Every dollar wasted on woo is a dollar not available to be spent on tx's buttressed by scientific evidence that they work.

apropos of current applied neuro-science, this just came to my attention. I will download and study this book forthwith:

"Most of us will freely admit that we are obsessed with our devices. We pride ourselves on our ability to multitask -- read work email, reply to a text, check Facebook, watch a video clip. Talk on the phone, send a text, drive a car. Enjoy family dinner with a glowing smartphone next to our plates. We can do it all, 24/7! Never mind the errors in the email, the near-miss on the road, and the unheard conversation at the table. In The Distracted Mind, Adam Gazzaley and Larry Rosen -- a neuroscientist and a psychologist -- explain why our brains aren't built for multitasking, and suggest better ways to live in a high-tech world without giving up our modern technology. The authors explain that our brains are limited in their ability to pay attention. We don't really multitask but rather switch rapidly between tasks. Distractions and interruptions, often technology-related -- referred to by the authors as "interference" -- collide with our goal-setting abilities. We want to finish this paper/spreadsheet/sentence, but our phone signals an incoming message and we drop everything. Even without an alert, we decide that we "must" check in on social media immediately.Gazzaley and Rosen offer practical strategies, backed by science, to fight distraction. We can change our brains with meditation, video games, and physical exercise; we can change our behavior by planning our accessibility and recognizing our anxiety about being out of touch even briefly. They don't suggest that we give up our devices, but that we use them in a more balanced way."
Heard the authors interviewed on the NPR Diane Rehm Show: "A Neuroscientist And A Psychologist On How Our Ancient Brains Work In A High-Tech World." Great 48 minute online audio discussion there. Well worth your time.

Things I will be looking for in particular are any implications for the irreducibly high cognitive burden environment of clinical workflow in a digital world. During my time in the Meaningful Use program, I was the goto guy for "workflow improvement" at my REC. It, and "process QI" more broadly, remains a core interest.

One interesting "Distracted Mind" connection I anticipate goes to Dr. Dan Lieberman's excellent book The Story of the Human Body: Evolution, Health, and Disease, which I cited back in April: Digital Health IT = "Better Care at Lower Cost." Right?

"Evolutionary mismatch" ailments. They extend to the brain and mind. And, we are now at a point where the exponentially increasing pace of anthropocene "cultural evolution" (which includes technology and is decidely Lamarkist) is utterly dwarfing that of biological evolution.

There may also be tangential / triangulation implications concerning these two current reads of mine.

Been a fan of Robert Cialdini's work for a long time, and the Dave Gray book was a total delight.

WATCH: Can exercise make you smarter? Scientists think it’s possible
...Wendy Suzuki, a psychologist at New York University ... runs a lab where she can carefully measure the [exercise] effect. Suzuki has volunteers run on a treadmill in her lab while she measures their oxygen consumption. Then she gives her subjects a battery of psychological tests to measure things like their memory and attention.

Suzuki has found that healthy people can improve their cognition with exercise right away. She has also found that people with brain injuries experience significant improvement in their mood. Now she’s running a class in which her students exercise at a gym three times a week, to see how their brains change over a full semester...


A long read by Trudy Lieberman (paywalled, but may be viewable once by non-subscribers):

“Don’t Touch My Medicare!”
Is the beloved program on its last legs?

...The Medicare Modernization Act poked yet another hole in Lyndon Johnson’s fraying compact. It called for wealthier beneficiaries—people with incomes above $85,000 if single or $170,000 if married—to pay higher premiums for Part B benefits. The provision moved through Congress with “unexpected support from some Democrats,” the New York Times reported. As the law neared final approval, though, the Times noted that AARP, the UAW, and liberal Democrats, including Senator Edward Kennedy, viewed some of its proposals as a “dangerous first step in turning Medicare from a universal social insurance program into a welfare program.”

In a sense, the conservative assault on Medicare is two-pronged. On the one hand, there is a drive to privatize. On the other, critics hope to rebrand Medicare as a variety of welfare. The former Hill staffer says that the Republicans have “been on a very consistent march for decades now. They basically want to get rid of the entitlement and want everything means-tested.” Means-testing—that is, basing eligibility for benefits on whether a person has the means to do without that help—saves billions for the government. But it would also make Medicare into the equivalent of food stamps or Medicaid. And that, of course, is the objective.

So far, privatization remains the more politically correct solution for Medicare’s financial shortfalls. These are real, at least potentially. In large part, they have been caused by the lack of serious cost controls, and exacerbated by the influx of millions of baby boomers needing medical services. Even the government’s attempts at cost control introduced during the Reagan era failed to permanently curb medical inflation. Indeed, containing the prices charged by the doctors, hospitals, drug makers, nursing homes, and home-care agencies that rely on the Washington gravy train has been an almost impossible task. The 2003 prescription-drug law, for example, prohibits Medicare from negotiating the prices it pays for drugs. “There are obstacles statutorily and politically,” says former Medicare administrator Don Berwick. “We can’t negotiate for purchasing, in one of the largest insurance systems in the world. The moneyed interests are calling the shots.”

Many of those moneyed interests sell health-care technology, which has long been a major cause of exploding costs. Richard Foster, who was Medicare’s chief actuary from 1994 to 2013, describes the situation: “As long as there’s an automatic market for new technology, even if it’s not any more effective, cost growth will keep going up.” In fact, Medicare has historically not considered cost effectiveness when deciding whether to cover new drugs and technologies...
Read all of it. Of particular interest to me these days, given that my wife and I are now Medicare benes. More broadly, this kind of policy stuff is every bit as important as clinical science, process QI, biotech, and health infotech. The finest clinical capability on earth is of nil utility if it's increasingly out of reach financially.

More to come...

Thursday, October 13, 2016

First World Problems

No, I obviously don't like the guy. No, not one whit. To extent that he ever talks policy, including health care policy, it's always the same mile-wide, inch-deep cliche ramble.

Less than four weeks to go to Election Day. It cannot come soon enough for me.

First World Problems.


‘There’s Going to Be Famine Here’: Hurricane Matthew’s Apocalyptic Aftermath in Haiti
After traveling through the once beautiful, now devastated peninsula that bore the brunt of the storm, it is hard to believe there will ever be a full recovery.

JÉRÉMIE, Haiti — The roads were lined with Gordian knots of massive uprooted trees, twisted, severed palms, torn corrugated roof parts, crushed rural dwellings, schools, local shops. Mile after mile the scenery repeated itself; the devastation growing with an eerie intensity. Leafless trees and palms had turned black, as if scorched by the storm, and stood like frozen, shaven sentinels in a sea of flooded fields for as far as the eye could see. Destruction was everywhere.

A three-day trip through Haiti’s hardest hit southern peninsula revealed the still-unimaginable scale of suffering Hurricane Matthew left behind, and the long-term catastrophic impact the tempest will have on this Caribbean island. More than 1,000 people are believed to have died. Fears are growing of a cholera epidemic. And despite some long-delayed aid deliveries, hopes for the future are fading...
Read the entire article. Heartbreaking.

More to come...

Thursday, October 6, 2016

The locus of Mind

I recently finished this excellent book. Is biological consciousness wholly neural, "brainbound?"

Patricia Churchland is touted as a "neurophilosopher." Lots of good neuroscience here, along with great philosophical musings, as well as bioevolution and social/cultural anthropology stuff.
I should again note that the word "philosophy" properly denotes "filo" (love of) "sophia" (knowledge), notwithstanding its rep as 50-dollar-word laden obtuse intellectual snobbery. i.e., properly the "science" of cognition and moral reasoning.
From the Amazon blurb.
A trailblazing philosopher’s exploration of the latest brain science—and its ethical and practical implications.

What happens when we accept that everything we feel and think stems not from an immaterial spirit but from electrical and chemical activity in our brains? In this thought-provoking narrative—drawn from professional expertise as well as personal life experiences—trailblazing neurophilosopher Patricia S. Churchland grounds the philosophy of mind in the essential ingredients of biology. She reflects with humor on how she came to harmonize science and philosophy, the mind and the brain, abstract ideals and daily life.

Offering lucid explanations of the neural workings that underlie identity, she reveals how the latest research into consciousness, memory, and free will can help us reexamine enduring philosophical, ethical, and spiritual questions: What shapes our personalities? How do we account for near-death experiences? How do we make decisions? And why do we feel empathy for others? Recent scientific discoveries also provide insights into a fascinating range of real-world dilemmas—for example, whether an adolescent can be held responsible for his actions and whether a patient in a coma can be considered a self.

Churchland appreciates that the brain-based understanding of the mind can unnerve even our greatest thinkers. At a conference she attended, a prominent philosopher cried out, “I hate the brain; I hate the brain!” But as Churchland shows, he need not feel this way. Accepting that our brains are the basis of who we are liberates us from the shackles of superstition. It allows us to take ourselves seriously as a product of evolved mechanisms, past experiences, and social influences. And it gives us hope that we can fix some grievous conditions, and when we cannot, we can at least understand them with compassion.
apropos, along comes an interesting article on the topic.

Where is your mind? 
Where does your thinking occur? Where are your beliefs? René Descartes thought that the mind was an immaterial soul, housed in the pineal gland near the centre of the brain. Nowadays, by contrast, we tend to identify the mind with the brain. We know that mental processes depend on brain processes, and that different brain regions are responsible for different functions. However, we still agree with Descartes on one thing: we still think of the mind as (in a phrase coined by the philosopher of mind Andy Clark) brainbound, locked away in the head, communicating with the body and wider world but separate from them. And this might be quite wrong. I’m not suggesting that the mind is non-physical or doubting that the brain is central to it; but it could be that (as Clark and others argue) the mind extends beyond the brain.

To begin with, there is a strong case for thinking that many mental processes are essentially embodied. The brainbound view pictures the brain as a powerful executive, planning every aspect of behaviour and sending detailed instructions to the muscles. But, as work in robotics has illustrated, there are more efficient ways of doing things, which nature almost certainly employs. The more biologically realistic robots perform basic patterns of movement naturally, in virtue of their passive dynamics, without the use of motors and controllers. Intelligent, powered control is then achieved by continuously monitoring and tweaking these bodily processes, sharing the control task between brain and body. Similarly, rather than passively gathering information to construct a detailed internal model of the external world, it is more efficient for the control system to keep actively probing the world (to ‘use the world as its own model’, as the roboticist Rodney Brooks puts it), gathering just enough information at each step to advance the task at hand. Such a strategy relies essentially on body activity. 

As well as being embodied, mental processes can also be extended to incorporate external artefacts. Clark and fellow philosopher of mind David Chalmers propose what’s since been called the Parity Principle, which says that if an external artefact performs a function that we would regard as mental if it occurred within the head, then the artefact is (for the time being) genuinely part of the user’s mind. To illustrate this, Clark and Chalmers describe two people each trying to work out where various shapes fit in a puzzle. One does it in his head, forming and rotating mental images of the shapes, the other by pressing a button to rotate shapes on a screen. Since the first process counts as mental, the second should too, Clark and Chalmers argue. What matters is what the object does, not where it is located. (Compare how a portable dialysis machine can be part of a person’s excretory system.) The rationale is the same as that for identifying the mind with the brain rather than the soul; the mind is whatever performs mental functions.  

The Parity Principle doesn’t apply only to processes we can in fact perform in our heads. Think about doing a long division with pen and paper. Few of us can do this in our heads, holding all the stages in memory, but if we could, we would certainly regard it as a mental process, so – applying the Parity Principle – we should regard the pen-and-paper process as a mental one, too. An extension can also be an enhancement.

Language is a particularly powerful means of extension and enhancement, serving, in Clark’s phrase, as scaffolding that allows the biological brain to achieve things it could not do on its own. Linguistic symbols provide new focuses of attention, enabling us to track features of the world we would otherwise have missed, and structured sentences highlight logical and semantic relations, allowing us to develop new, more abstract reasoning procedures (as in long division). With pen or laptop, we can construct extended patterns of thought and reasoning that we could never formulate with our bare brains. In writing, we are not simply recording our thinking but doing the thinking. (As the physicist Richard Feynman once observed: ‘I actually did the work on the paper.’)

Clark and Chalmers propose that mental states, such as beliefs, can also be located externally. They imagine a character, Otto, who has Alzheimer’s disease and uses a notebook to store the information he needs to guide his daily activities. When he needs to recall an address, Otto consults his notebook instead of his biological memory, and Clark and Chalmers suggest that the notebook literally contains his belief about the address. It functions as an external memory (like a flash drive) linked to the rest of Otto’s mind via a perceptual interface. Clark and Chalmers stress that the link must be tight in order for the notebook to have this status: Otto must have it constantly with him, must be able to access its contents easily, and must trust what is written there. (Thus, the contents of the reference books stored on the shelves in his house are not counted as his beliefs.) Of course, the belief in Otto’s notebook is not a conscious one (until Otto consults the book), but neither are the beliefs stored in our brains until we call them to mind.

As the philosopher of mind Daniel Dennett notes, many elderly people are in Otto’s position, relying on a host of cues around the home to guide them through their daily routines, reminding them of what to do, and when, and how. As their memories fail, they have offloaded work onto the external environment, and taking them from their homes is, as Dennett puts it in Kinds of Minds (1996): ‘literally separating them from large parts of their minds – potentially just as devastating a development as undergoing brain surgery’.

You might want to ask why we should think of minds extending into bodies and artefacts, rather than merely interacting with them. Does it make any difference? One answer is that, in the cases described, brain, body and world are not acting as separate interacting systems, but as a coupled system, tightly meshed by complex feedback relations, and that we need to look at the whole in order to understand how the process unfolds. (It’s worth noting, too, that the brain itself is a collection of coupled subsystems.)

Of course, we think of ourselves as being situated in our heads. But that is because of how our perceptual systems model the world and our location in it (reflecting the location of our eyes and ears), not because our brains happen to be in there. Imagine (if it isn’t too gruesome) having your living brain temporarily removed from your skull, nerve connections intact, so that you could hold it and look at it. You would still seem to be in your head, even though your brain was in your hand.

If the mind is not bounded by the brain or the skin, where does it stop? What is the boundary line? The short answer is that there isn’t one – not a stable one, at any rate. The mind expands and shrinks. Sometimes (in silent thought, for example) mental activity is confined to the brain, but often it loops out into the body and external world. It’s a slippery thing, which can’t be contained.

Aeon counter – do not remove
Keith Frankish

This article was originally published at Aeon and has been republished under Creative Commons.
"If the mind is not bounded by the brain or the skin, where does it stop? What is the boundary line? The short answer is that there isn’t one..."

Yeah, paraphrasing Zukav: "Everything is part of that which is. Even that which is not is part of that which is. Even if that which is is an "illusion," even that illusion is." - The Dancing Wu Li Masters

See also my post "A speculation on the afterlife."


Really? We going all  techno "GAIA" now? From Jeff Stibel's interesting book.

Throughout this book, the internet has been used as an analog to the brain because both are complex networks. But there are even more fundamental similarities, which I would argue are evidence that the internet is not merely like a brain but is a brain. While not central to the concept of breakpoint, these ideas are significant in developing a full understanding of the potential of the internet, especially as it relates to artificial intelligence. 

The important question is this: Could the internet itself be made to perform more like a brain or even perform the functions of a brain— just as a hearing aid performs the function of the inner ear, or a contact lens performs the function of the cornea, or an artificial heart performs the function of that biological muscle? 

A computer is generally a poor analogy to a brain. It’s true that semiconductors switch on and off like neurons, and that fibers of glass can transmit messages like synapses and axons, but that’s where the analogy ends. Our computers are not nearly as analogous to the brain as, for example, an artificial heart is to a real heart. 

The internet, however, is unlike anything humankind has built before. All of our previous inventions— steam locomotives, television sets, cars— are inert. Chessboards and baseball stadiums may flicker to life momentarily, but go dark when the game is done. The internet is different. It’s unbounded, self-perpetuating, and capable of collective consciousness. It’s more like the crowd watching the baseball game than the stadium itself. 

Of course, every innovation that delivers something greater than the sum of its parts is miraculous. Alexander Graham Bell attached two small drums to two wire coils and out of those bits created something beyond the sum of the parts: sound. But the telephone did not go on to replicate and improve itself. The internet can and does. And beyond that, the internet learns. It processes information, shapes it, transmits it. It remembers some things, forgets others, and constantly loops whatever it has again and again, spinning it in as many ways and in as many directions as one could imagine. 

Without a strong understanding of what a brain actually is, it may seem preposterous to say that the internet is a brain. The internet is not the three-pound wrinkled gray glob that most of us conjure up as an image of the brain. Actually, that’s not even what the brain is. The brain is nearly 60 percent white matter— the tissue that connects neurons— with only the remainder being the gray stuff we typically think of. The gray matter contains the all-important neurons, but the connections are equally important. 

Outside of the deep ridges and two hemispheres, most people wouldn’t recognize a brain if presented with one. The brain is very soft, almost jellylike, and ivory in color with deep burgundy-colored veins. The brain doesn’t take on a firm gray appearance until it’s dead, bloodless, and preserved. This visual distinction is important because it tells us that a living brain is consuming massive amounts of energy in the form of blood flow. 

But even that description is somewhat misleading. In the way the brain actually functions, it is far more similar to a piece of paper. The paper represents the outermost area of the brain, the cerebral cortex. It is here that most of the magic of thought takes place. Imagine this piece of paper: thin, rectangular, and mostly blank to start. On the paper are bits of information that grow as the brain is formed, like braille embossed on the page. Those are the neurons, and they help to store and process information. 

The ingenuity of the brain comes not from the informational elements but from how that information is physically connected. Imagine crumpling the piece of paper into a ball. Two dots at either end of the page are far away from each other initially. But as you crumple the paper, the dots get closer. Crumple it enough times, and every point will be in striking distance of every other point. Our brains are folded and crumpled into our skulls in just this manner, and their unique power comes from the ability to connect disparate pieces of information for quick communication and interdisciplinary learning. 

In terms of the computer industry, the human brain is a sophisticated “parallel processing” machine. That means that it does a number of things at the same time, unlike “serial computing” in which one thing happens, then another, and then another. Neuroscientists call this “distributed computing,” meaning that since the functions of the brain are distributed all over the place, things can happen simultaneously. (“ Distributed” is a more accurate term than “parallel” because parallel computing conjures up the idea of two unbending parallel lines, like railroad tracks, whereas “distributed” is a freewheeling image that describes more accurately how the brain actually works.)
A neuron consists of the soma, an axon, and dendrites. Think of the soma as the center of the neuron or the information clearinghouse. The axon acts as a transmitter, sending information from one neuron to another. The dendrites receive information from other neurons. Neurons communicate with one another through electrical and chemical transmitters. These tightly packed neurons work together in a distributed network, forming patterns that allow us to perform tasks such as walking, speaking, remembering someone’s name, and even reading this book.
Stibel, Jeff (2013-07-23). Breakpoint: Why the Web will Implode, Search will be Obsolete, and Everything Else you Need to Know about Technology is in Your Brain (Kindle Locations 2338-2378). St. Martin's Press. Kindle Edition.
'eh? Yet another intriguing read. Implications for "AI" at every turn.

Sam Harris: Can we build AI without losing control over it?

@~5:30: "We will continue to improve our intelligent machines. And given the value of intelligence -- I mean, intelligence is either the source of everything we value or we need it to safeguard everything we value. It is our most valuable resource. So we want to do this. We have problems that we desperately need to solve. We want to cure diseases like Alzheimer's and cancer. We want to understand economic systems. We want to improve our climate science. So we will do this, if we can. The train is already out of the station, and there's no brake to pull..."
Recall Gerd Leonhard's "Digital Ethics," anyone?


apropos of "neural" stuff, some news from Jeff and April's startup.

April is my sister's elder daughter. I am way close with my sis and her kids. April's husband Jeff Nyquist is this brainiac dude with a PhD in neuropsychology from Vanderbilt. A core focus of their VR-assisted technology is concussion prevention, mitigation, and remediation in the "collision sports."

They reportedly recently scored their first major sports league client contract, with the NHL Nashville Predators.

Their tagline is "Train From the Neck UP."

Bears watching.

More to come...

Dying? Trump asks that you postpone your demise until after Nov 8th

Always the classy guy.

Trump To Dying People: Stick Around Long Enough To Vote For Me
“I say kiddingly, but I mean it.”

“I don’t care how sick you are,” Trump said at a rally in Henderson, Nevada. “I don’t care if you just came back from the doctor and he gave you the worst possible prognosis, meaning it’s over, you won’t be around in two weeks. Doesn’t matter. Hang out till Nov. 8. Get out and vote.”

Speaking with his signature arrogance, Trump then assured those dying people that after they are gone, “all we’re going to say is, ‘We love you and we will remember you always.’”
From the Huffington Post.

There are no words.

Monday, October 3, 2016

#health2con 10th annual conference recap and photo gallery

The slide in the photo above neatly poses the summary questions: "The New Delivery System? What's The Future of Tech-Enables Services?"

Recall my slide shot from Day One.

Those comprise the core questions and challenge, no?

BTW, mark your calendars. Next up, January 11th, 2017.

I will certainly be there again.

OK, I had to put all this stuff down Friday to resume my ongoing weekly role as the world's most overeducated Senior Dog Rescue Shelter volunteer laundromat attendant at Muttville.org, now that Jaco is back home safe after having gone missing for 12 excruciating days.

One bonus: I finally finished this book while on BART:

Excellent discussions of neuroscience (and "philosophy of science" more broadly), evolution, and cultural/social anthropology, from the perspective of a "neurophilosophy" educator and researcher. Fits nicely with other recent reads of mine. See, e.g., "Evolution, science, technology (including Health IT), and the future of cognition."

Santa Clara conference media coverage note. Every day I'd search Google News for "Health 2.0" reportage, and was dismayed to see only a handful of daily "news" items about the conference -- most of them lazily and uncritically regurgitated brief press releases.

On September 30th, however, we finally got some meat. Props to MobiHealthNews.
In-Depth: News recap of Health 2.0's Fall Conference

This week in Santa Clara marked the 10th anniversary for Health 2.0, a health tech conference held every year in Silicon Valley to explore the progress being made in the digital health space and the challenges that remain. MobiHealthNews was onsite all four days of the conference and below we’ve rounded up our coverage of the event, plus quite a few presentations and bits of news that didn’t make the newsletter earlier this week.

Snake oil revisited

Though the buzz has finally started to fade from the news cycle, Health 2.0 cofounder Matthew Holt couldn’t resist bringing American Medical Association CEO James Madara on stage to take him to task for his now famous “snake oil” comments from the Spring.

“Last year, you sat here in this chair and you were super nice to us,” Holt joked. “Then, I’m on my vacation in Vietnam and my Twitter feed starts blowing up with this snake oil stuff. Do you love us or do you hate us?”

Madara responded that “there is love and there is hate”, citing the AMA’s work with Omada Health as an example of a digital health intervention he loved and the troublingly inaccurate blood pressure app Instant Blood Pressure as one he hated.

“Why raise a siren now with this intentionally used term ‘snake oil’? The reason now is I think we’re in a period of criticality for [digital health]. The criticality is that there’s no regulatory framework. I think digital health is going to be part of the transformation of healthcare. But if this is so important for healthcare, does anyone think that it’s going to continue to be unregulated?”

Madara thinks the industry needs self-regulation of apps and connected devices that’s robust enough that HHS will grant legitimacy to those efforts. He thinks relying too heavily on the FDA could result in regulations that are “heavy-handed, they overreach, and they’re one-size-fits-all”...

Yeah. Recall my May post "Is the Fitbit "For Entertainment Purposes Only"?

apropos, also from MobiHealthNews:
Digital health VCs talk strategy, trends, and a plea for an end to metaphors

...Sven Lingiaerde, a managing partner at Swiss firm Endeavour Vision, said he wanted to see fewer fitness and beauty apps navigating into the so-called ‘gray line’ into healthcare.

“No more free yoga apps,” he said. “Wellness in general, I’m not convinced you can be that profitable. Direct to consumer products have to have a lot of money in the beginning and you have to be very close to the people who you are offering your product to. We want to see more business to business.”

What investors also want, they said, is more focus on behavioral health analytics, more hospital-focused innovation, and investment strategies wherein funders are carefully aligned to offset the inevitable future friction as the company matures and, possibly, ends up with a different mission from which it set out with....
See also my prior post "Digital Obesity."


OMG. The Robin Williams of Health IT.

Again, citing MobiHealthNews:
Health 2.0 move over, Health 3.0 is here
 A few days before the conference, healthcare investor Dave Chase and athenahealth CEO Jonathan Bush teamed up to pen an editorial arguing that Health 1.0 — healthcare before computers was inefficient, but healthcare today (Health 2.0) has lost the human touch and made doctors spend too much time in service of EMRs and documentations. The next era in healthcare, they argue, will combine the best aspects of the two, and make technology serve patient care, rather than the other way around.

Bush took the stage on Wednesday and expounded on some more of the specifics of that idea, saying that it would take large EHR vendors committing to a real connectivity to allow the real value of digital health technologies to scale.

“You’ve got all these ideas, you do the demos, they make sense,” he said. “But they don’t explode, they don’t lift off. I think people will get out of enterprise software or the enterprise software companies will remake themselves. You’re already seeing the Mad Hatter talking about pulling the various instances of Epic together, making it more of a network. As that happens, that concept of an internet makes the ability to really blow out, to make money quickly a possibility in healthcare.”...
I hope someone posts video of this hilarious encounter between Jonathan and Matthew. Worth the price of admission. See Jonathan Bush and Matthew Holt at HIMSS15, YouTube.
Note: After citing the late Robin Williams analogy above, I had second thoughts in the wake of reading "The terrorist inside my husband's brain," just written by his widow. Achingly sad. The repeated misdiagnoses, man... I never knew Robin, but I do have a tangential connection. What a terrible loss.

Those remain core topics of interest to me. First, will genome-based "personalized medicine" live up to its hype any time soon? One of my abiding concerns, irascible old-school lab QA guy that I am:

See my prior posts on the topic. Again, what of genetic assay QA and clinical dx competency?

Also, given the huge volumes of "GATTACA gibberish" data, Personalized Medicine will require both "AI" and "IA."

This session didn't provide much comfort. Precious little on the actual applied analytical science.


Yeah. "Standards."

How about "Standard Data"? Will the maturation of APIs essentially congeal into interoperable and n-dimensionally cross-platorm, iteratively/recursively durable, (and transactionally frictionless) "standard data" exchange? The "Type-O blood" of health care? That whole "information is the lifeblood of medicine" thing?

Redox claims that their product turns an entire EHR into an "API."

"We empower healthcare applications to read, write, and query clinical data with any healthcare organization's
electronic health record system. The bridge to interoperability is open."

Allscripts touts its Open API Developer Program.

MU3 snips:
Patient Electronic Access to Health Information
Measure 1 – More than 80% of all unique patients seen by the EP (i) The patient (or patient-authorized representative) is provided access to view online, download, and transmit their health information within 24 hours of its availability to the provider; OR (ii) The patient (or patient-authorized representative) is provided access to an ONC-certified API that can be used by third-party applications or devices to provide patients (or patient-authorized representatives) access to their health information, within 24 hours of its availability to the provider...

Coordination of Care through Patient Engagement
Measure 1 – For more than 25% of all unique patients seen by the EP actively engage with the electronic health record made accessible by the provider. An EP may meet the measure by either: (i) patient view, downloads, or transmits to a 3rd party their health information; or, (ii) patient access their health information through the use of an ONC-certified API that can be used by third-party applications...
We shall see. Recall my post of two years ago "Interoperability solution? HL7® FHIR® -- We ® Family."

I had a nice chat with the crazy smart Erik Kins of Allscripts. He just posted here:
Electronic health records (EHRs) are the backbone of health IT infrastructure, but they can’t be all things to all people. For truly connected communities of health, EHRs must talk with other applications and solutions.

Integrating separate technologies has not always been easy. Traditionally, these projects require committee meetings and complicated interfaces that can take months, or even years, to complete.

Allscripts has redefined the paradigm for health IT interfaces. With an open platform, clients can customize their EHRs in a matter of weeks, days – and lately, even minutes...

BTW: I'd reached out to MI7 (Redox competitor?) prior to the Conference. They did not attend.

I will certainly probe them further.


I guess if you want serious meat on "workflow" (care delivery processes) you need to attend the annual Lean Healthcare Transformation Summits. (See here as well.) While the word "workflow" got loosely bandied about a good bit at the Health 2.0 conference, process QI is really not the focus.


ONC National Coordinator Dr. Vindell Washington
Veterans Administration CIO and Assistant Secretary Laverne Council

Requisite lofty keynote and interview rhetoric aside, we're in a bit of an actionable policy leadership lull these days as we lurch toward 2016 election day. Should Hillary Clinton win -- and -- Senate control shift to the Democrats, we stand a good chance of seeing revitalized federal activism on the health care fronts.

Then, alternatively of course, there's Donald Trump.


The "E-Patients"
The always fabulous Alexandra Drane
Dr. Mike Painter and Esther Dyson
Keynoter Ian Morrison

That's enough for now. I have more.

I am gonna have to figure out an efficient way to capture photo caption info for every shot I take. Stuff goes by too fast, and I can't stop and jot down names etc every time I click the shutter. Then, in the blur of activity, I frequently forget who was exactly whom amid those people I don't already know.

I do the photography mainly to give you a visual sense of what it's like to be there (and, because historically it's how I roll, going back to my days as the go-to "20 Feet From Stardom" photographer in Vegas). All of the other Health InfoTech reportage is pretty much  standard journalism "text-only" -- e.g., the excellent MobiHealthNews article cited above. I first covered these kinds of Health Care / Health IT events in Feb 2012 when HIMSS, to my utter surprise, gave me a press pass. Even though I retired from my Meaningful Use REC in May, 2013, I continue to do this simply because it's important -- and personally interesting. I've never tried to "monetize" the effort. I launched this blog simply as an online episodic (and sometimes irascible and snarky) work "diary" in 2010 shortly after hiring on for the REC initiative.

I started this post on Saturday (it's now Monday morning), but came down ill with some enervating bug. Stayed in bed pretty much all day yesterday.

I still have to go back through my notes spread across my little old eClinicalWorks notebook and scribbled through the conference program and session handouts. So, there will be more upon which to reflect.

BTW: Another (relatively brief) piece of reportage has appeared, via MediCityNews:
From smart socks for diabetes to hand rehab: Health 2.0’s most interesting startups
October 1st

One tradition of Health 2.0 is that it offers a launchpad for digital health companies that are rising above the radar into public view. Referred to as LAUNCH!, it spotlights as many as 10 companies. The most interesting companies spanned physical therapy, the microbiome and fraud...

This post has run so long that prior #health2con 2016 posts in the KHIT blog feed don't show when you scroll down. So, chronologically...
I guess one summary take I have with regarding much of what I witnessed at the 2016 conference -- with respect to the endless onslaught of emergent app demos, anyway -- is that I kept having a "yeah, Trivago / Compare.com" reaction. You know; the ongoing blizzard of web- and smartphone based consumer offerings we see on TV every day, all promising E-Z frictionless, inexpensive instant gratification for your every need.

The "Look & Feel" aesthetics UX was pretty much all bright and shiny. Great use of colors and artsy layouts, I have to say.

A hell of a lot nicer looking than the typical mainstream EHR. But, given the relative niche narrowness of each new app, that's a much easier lift. And, I find the assertions that "we are now in a post-EHR world" (which I heard proffered more than once at the conference) just a tad fatuous.

Still a lot of "Free Beer Tomorrow" syndrome in place. But, in terms of health infotech maturities, we are likely at numerous places on the "transformative" exponential progress "hockey stick" curve.

The health tech space is not unique in this regard. "Keep Calm and carry On."


Among other topics, some new book reports shortly.

Finished both Liminal Thinking and Breakpoint. Just staring Pre-suasion.

More to come...