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Tuesday, November 13, 2018

California is on fire once again

From The Atlantic:
Smoke From California’s Fires Is Harming the State’s Most Vulnerable
As wildfires burn out of control, they are impacting the state’s other crisis—the growing number of people living on the streets.

The deadliest fire in California’s history continues to burn, and San Francisco is filled with smoke and ash. On Tuesday, for the fifth day in a row, air throughout Northern California contained high amounts of fine-particulate-matter pollution, and the Bay Area Air Quality Management District warned that the air was unhealthy for everyone. “The public should limit outdoor activity as much as possible,” the agency said Monday, urging residents to stay inside with their windows and doors closed.

But for San Francisco’s thousands of homeless people, this warning is impossible to follow. San Francisco, like many California cities, has seen homelessness rise in recent years, as the cost of housing has gone up and zoning laws have limited the construction of new housing units. Despite an initiative passed on November 6 to tax large businesses to fund homeless services and news that the CEO of Twilio had donated $1 million to fund homeless services until the tax kicks in, thousands of people still have nowhere to go in San Francisco on any given night. As the number and deadliness of fires grows in California, the population of people negatively impacted by the air quality is growing, too…
In addition to our long-time chronic homeless population issue, we now have thousands of people newly made homeless by our fires. Same thing last year with the wine country fires. I can't imagine. 

My eyes have been burning since last Friday, and I've had a heavy feeling in my chest, notwithstanding being 140 miles to the southwest of the closest fire near Chico. Our area in Antioch smells like BBQ, the sky a chalky grey-yellow, with the sun a dull orange-reddish orb. We were all advised to close windows, bring the dogs in, and stay inside. On Sunday the manager of my Muir cardiac rehab PT clinic called to say that PT was cancelled for Monday and perhaps today as well. As I post this the death toll has risen to at least 44, with hundreds of people yet missing.

Numerous vehicles have literally melted along the roads. Thousands of structures have been reduced to ashes (some with human remains cremated inside).


Before-and-after pics from one street corner.


BTW: look under your sinks, and out on your garage shelves. Ponder all of those toxic household cleaning products, paints, solvents, landscaping, herbicides, pesticides, and automotive chemicals, etc. The smoke cloud now enveloping us is full of them in addition to burned wood and grass particulates (along with what used to be plastics).

I first came to the Bay Area in 1967 (subsequently lived in Seattle, Birmingham and Tuscaloosa AL, Knoxville TN, and Las Vegas, prior to returning here in 2013). The California population has since more than doubled, from ~19 million to more  than 39 million people. Along with population pressure, persistent drought, exacerbated by climate change has contributed significantly to the frequency and severity of western wildfires.

Tangentially, time for deployment of "exposomics" monitoring tech in fire-affected areas?
No rain in sight for us yet.


Cardiac rehab was open today, btw. Good workout.

The Atlantic has another good one up on widfires:

The Simple Reason That Humans Can’t Control Wildfires



High Stakes, Entrenched Interests And The Trump Rollback Of Environmental Regs

Since his days on the campaign trail, President Donald Trump has promised to roll back environmental regulations, boost the use of coal and pull out of the Paris climate agreement — and he’s moving toward doing all those things.

He has pushed ahead with such action even as a report by the United Nations’ Intergovernmental Panel on Climate Change released in October concluded that without much stronger measures to reduce the use of fossil fuels, a warming planet will witness the spread of tropical diseases, water shortages and crop die-offs affecting millions of people.

Supporters of the administration’s changes — some of whom are skeptical of accepted science — say the administration’s moves will save money, produce jobs and give more power to states.

But critics say new strictures on scientific research and efforts to overturn standards for protecting air, water and worker safety could have long-term, widespread effects that would upend hard-won gains in environmental and public health.

The Trump administration’s many environmental proposals vary widely in target and reach.
For example, the administration has delayed the implementation and enforcement of many Obama-era rules, saying they need time to draw up new rules or study some that are already on the books. Industry generally agrees, arguing these rules are an overreach with negative financial consequences. 

Critics fear that the delays will undermine hard-fought public health protections.

Among such efforts:
The Environmental Protection Agency recently argued it needs until 2020 to decide on a controversial Obama-era directive expanding to smaller streams and waterways the types of wetlands protected by the federal Clean Water Act. That directive might mean fewer pollutants released into tributaries of larger waterways, from which millions of people get their drinking water. But the controversial rule has been fought by farming, mining and other industry groups that say it is too restrictive.
The EPA also sought to delay by nearly two years standards to protect workers and emergency responders at chemical plants, part of an Obama-era rule in response to a 2013 fire at a Texas fertilizer plant that killed 15 people. Industry says that the rule is costly and that providing information about chemical storage at plants could raise security concerns.
In March 2017, then-EPA chief Scott Pruitt rejected a petition filed in 2007 by environmental groups seeking to ban a commonly used pesticide, chlorpyrifos, which the groups say harms health, particularly citing developmental damage to children and fetuses. The agency said it needed more time to study the chemical. 
All three of those delays were blocked by federal court judges, although the administration may decide to appeal, so final outcomes are unclear.

But one thing is clear: Everyone is likely to spend a lot of time in court.

“Folks are already lining up to challenge the Affordable Clean Energy rule, and that’s probably true for just about anything this administration does when it comes to environmental reform,” said Nicolas Loris, a research fellow at the Heritage Foundation, a conservative think tank.

The clean energy rule, introduced in August, would replace a more stringent Obama-era rule for coal-burning power plants.

An EPA analysis said the proposed rule would reduce industry costs and create jobs.

The same analysis concluded, though, that the looser standards, which would supersede the never-implemented Obama-era regulation, would cause as many as 1,400 premature deaths and 15,000 new cases of upper respiratory problems annually by 2030.

On another front, scientists are protesting new Trump administration policies they say would effectively curtail their ability to study the health effects of environmental exposures.

This spring, the EPA proposed a rule dubbed Strengthening Transparency in Regulatory Science, which would restrict the use of studies as the basis for advancing environmental regulations if researchers have not released all their raw data, potentially including medical records.

The Trump administration said this step would ensure that data and methods can be checked for accuracy, echoing a long-running argument from industry and some in Congress.

From scientists, though, reaction was immediate, widespread and negative. Hundreds of researchers and dozens of public health organizations said the proposal would quash important research into the effects of pollution and chemicals on health.

No longer would they be able to promise confidentiality of medical records to people who take part in research studies, which would have a chilling effect on their willingness to participate.

Many of the submitted comments noted that such a rule would undermine key studies that led to pollution laws and prevailing attitudes about the interaction of environmental and human health.
Case in point: the seminal 1993 “Six Cities” research by Harvard scientists linking air pollution to premature death.

That study did not disclose the identities of its 22,000 participants or their medical information.
Its findings led in 1997 to new restrictions under the Clean Air Act for fine particles, tiny pieces of soot, dust, carbon and other pollutants that get inhaled deep into the lungs, potentially causing asthma, lung cancer and other health conditions. By 2020, those rules are expected to have prevented more than 230,000 early deaths.

Scientists say the administration is handicapping their ability to do important research. The plan comes amid other efforts critics see as attacking science, such as removing information from government websites about climate change, restrictions on who can sit on EPA advisory boards and a proposal to more narrowly target safety reviews of chemicals.

“By attacking the science that talks about adverse effects on health,” the administration hopes to allow deregulation yet claim “they are not harming people,” said Francesca Dominici, a professor of biostatistics at the Harvard’s T.H. Chan School of Public Health.

The range and scope of the proposed changes has brought praise from some in industry and agriculture for loosening restrictions and giving states more flexibility. But the changes frustrate public health and environmental health advocates.

“We would like to be moving forward rather than fighting these kind of rollbacks,” said Janice Nolen, assistant vice president for national policy at the American Lung Association.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
Is it too early to start drinking?


The air here remains "unhealthy." It was chokingly smoky today, with a sharp burnt odor. The wildfires body count continues to rise (63 as I write, hundreds still missing). More than 10,000 structures destroyed or damaged (mostly destroyed). Thousand are now homeless, many near Paradise sleeping in cars or tents in a Walmart parking lot.

I had cardiac rehab PT today. Pushed it hard. Felt good, but now I can feel it in my chest. Staying in the house.


More than 630 people reported as missing in the #CampFire area. More than 15,000 structures destroyed. The Bay Area air is so bad that UC Berkeley has closed for the day (as well as Contra Costa County schools). And, coming soon:

No, again, I don't like him.

From Vox:


In The New Yorker

Spot-on CNN OpEd by Tess Taylor. "In California, the apocalypse keeps getting worse."


Finished two books.

Both excellent, both broadly germane to KHIT topics.

Starting two more (notwithstanding that I still have a number of others in progress. Amazon "Buy with 1-click" is gonna BK me).

So much to learn. Love it. Given that we pretty much still have to stay inside, I'm grinding away with my studies,

Topically apropos, I read a Naked Capitalism post, which led me to this (and subsequent interesting stuff):

Startup Boom a “Dangerous, High-Stakes Ponzi Scheme”: Silicon Valley Investor

And, oh, yeah, I finished this one:

The less said about it, the better. I can't recall ever before having a book make me angry.

More to come...

Friday, November 9, 2018

"Epic fail?" Atul Gawande on the EHR

From an excellent New Yorker long read.

The article has an accompanying audio transcript that runs 59.07. Read/listen to all of it.
“Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.”
Take it from the top. Atul Gawande, MD:
On a sunny afternoon in May, 2015, I joined a dozen other surgeons at a downtown Boston office building to begin sixteen hours of mandatory computer training. We sat in three rows, each of us parked behind a desktop computer. In one month, our daily routines would come to depend upon mastery of Epic, the new medical software system on the screens in front of us. The upgrade from our home-built software would cost the hospital system where we worked, Partners HealthCare, a staggering $1.6 billion, but it aimed to keep us technologically up to date.

More than ninety per cent of American hospitals have been computerized during the past decade, and more than half of Americans have their health information in the Epic system. Seventy thousand employees of Partners HealthCare—spread across twelve hospitals and hundreds of clinics in New England—were going to have to adopt the new software. I was in the first wave of implementation, along with eighteen thousand other doctors, nurses, pharmacists, lab techs, administrators, and the like.

The surgeons at the training session ranged in age from thirty to seventy, I estimated—about sixty per cent male, and one hundred per cent irritated at having to be there instead of seeing patients. Our trainer looked younger than any of us, maybe a few years out of college, with an early-Justin Bieber wave cut, a blue button-down shirt, and chinos. Gazing out at his sullen audience, he seemed unperturbed. I learned during the next few sessions that each instructor had developed his or her own way of dealing with the hostile rabble. One was encouraging and parental, another unsmiling and efficient. Justin Bieber took the driver’s-ed approach: You don’t want to be here; I don’t want to be here; let’s just make the best of it.

I did fine with the initial exercises, like looking up patients’ names and emergency contacts. When it came to viewing test results, though, things got complicated. There was a column of thirteen tabs on the left side of my screen, crowded with nearly identical terms: “chart review,” “results review,” “review flowsheet.” We hadn’t even started learning how to enter information, and the fields revealed by each tab came with their own tools and nuances.

But I wasn’t worried. I’d spent my life absorbing changes in computer technology, and I knew that if I pushed through the learning curve I’d eventually be doing some pretty cool things. In 1978, when I was an eighth grader in Ohio, I built my own one-kilobyte computer from a mail-order kit, learned to program in basic, and was soon playing the arcade game Pong on our black-and-white television set. The next year, I got a Commodore 64 from RadioShack and became the first kid in my school to turn in a computer-printed essay (and, shortly thereafter, the first to ask for an extension “because the computer ate my homework”). As my Epic training began, I expected my patience to be rewarded in the same way.

My hospital had, over the years, computerized many records and processes, but the new system would give us one platform for doing almost everything health professionals needed—recording and communicating our medical observations, sending prescriptions to a patient’s pharmacy, ordering tests and scans, viewing results, scheduling surgery, sending insurance bills. With Epic, paper lab-order slips, vital-signs charts, and hospital-ward records would disappear. We’d be greener, faster, better.

But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one…
Fascinating. While I'm now 5 years out of the daily EHR trenches professionally, my world has been "all Epic all the time" ever since, in my roles as a patient (2015 prostate cancer dx & tx, 2018 SAVR px) and caregiver to my now-late younger daughter (2017-2018 pancreatic cancer dx & tx). All the major players here in the Bay Area -- Kaiser, Sutter, Muir, Stanford, UCSF -- are on Epic. I continue to be an acute observer of the EHR workflows I witness at every encounter, and I frequently query my clinicians about their experiences using Epic.

Nearly all I have seen during our many patient encounters across the past few years has been that of clinicians at all license levels whipping around the Epic EHR at lightning speed. Yes, they also all grouse about what they see as nuisance diversionary billing and compliance documentation, but the clinical care aspects of the EHR are about as efficient as you could hope for. That there are hundreds to thousands of clinical variables to be recorded and tracked is simply a core reality of medical care -- not the fault of the EHR.

Paper is not better.

Dr. Gawande:
“… the computer, by virtue of its brittle nature, seems to require that it come first. Brittleness is the inability of a system to cope with surprises, and, as we apply computers to situations that are ever more interconnected and layered, our systems are confounded by ever more surprises. By contrast, the systems theorist David Woods notes, human beings are designed to handle surprises. We’re resilient; we evolved to handle the shifting variety of a world where events routinely fall outside the boundaries of expectation. As a result, it’s the people inside organizations, not the machines, who must improvise in the face of unanticipated events.”
I am reminded of my prior post "Are structured data the enemy of health care quality?" Also, see my "Update on our favorite whipping boy, the EHR."
I might note that the bulk of the litany of complaints set forth in the Gawande article (and those of many others) are hardly news to those of us who have been involved in the EHR wars. I've been listening to these gripes since I came to the health IT space in 2005 with the onset of the QIO 8SOW "DOQ-IT" program.
Responding to the immediately foregoing Gawande observation inescapably leads me to, among other resources, this glorious book I recently finished.

"AI" to the rescue? Skeptics remain legion (including eminent AI pioneer Judea Pearl).
Big Data and causal inference together play a crucial role in the emerging area of personalized medicine. Here, we seek to make inferences from the past behavior of a set of individuals who are similar in as many characteristics as possible to the individual in question. Causal inference permits us to screen off the irrelevant characteristics and to recruit these individuals from diverse studies, while Big Data allows us to gather enough information about them.

It’s easy to understand why some people would see data mining as the finish rather than the first step. It promises a solution using available technology. It saves us, as well as future machines, the work of having to consider and articulate substantive assumptions about how the world operates. In some fields our knowledge may be in such an embryonic state that we have no clue how to begin drawing a model of the world. But Big Data will not solve this problem. The most important part of the answer must come from such a model, whether sketched by us or hypothesized and fine-tuned by machines…

Pearl, Judea. The Book of Why: The New Science of Cause and Effect (p. 352). Basic Books. Kindle Edition.
Now, while none of that speaks to the chronic, clinically enervating "productivity treadmill" concerns so adroitly addressed by Dr. Gawande, it is nonetheless relevant more broadly.

Regarding Dr. Gawande's "brittleness" characterization of computers, Dr. Pearl:
The goal of strong AI is to produce machines with humanlike intelligence, able to converse with and guide humans. Deep learning has instead given us machines with truly impressive abilities but no intelligence. The difference is profound and lies in the absence of a model of reality.

Just as they did thirty years ago, machine learning programs (including those with deep neural networks) operate almost entirely in an associational mode. They are driven by a stream of observations to which they attempt to fit a function, in much the same way that a statistician tries to fit a line to a collection of points. Deep neural networks have added many more layers to the complexity of the fitted function, but raw data still drives the fitting process. They continue to improve in accuracy as more data are fitted, but they do not benefit from the “super-evolutionary speedup.” If, for example, the programmers of a driverless car want it to react differently to new situations, they have to add those new reactions explicitly. The machine will not figure out for itself that a pedestrian with a bottle of whiskey in hand is likely to respond differently to a honking horn. This lack of flexibility and adaptability
[emphasis mine -BG] is inevitable in any system that works at the first level of the Ladder of Causation… [Pearl, pp. 30-31]
"Lack of flexibility and adaptability" -- i.e., "brittleness."

You'd have to study the entire Pearl book to fully appreciate that AI has quite a way to go before it significantly enables digital workflow "adaptability" borne of "causal reasoning" capacity, particularly in the complex data health IT space. Nonetheless, there remains a lot that can be accomplished below the "strong AI" level to get us closer to more digitally "frictionless" clinical workflow usability. 

BTW, apropos, see also my prior posts concerning "The Digital Doctor."

Stay tuned.

More to come...

Thursday, November 8, 2018

Deadly mass shooting in Thousand Oaks, CA

Reportedly 12 dead victims (plus the 28 year old ex-Marine gunman), many others wounded. Mindless. 307th U.S. mass shooting in 2018.
Thus far.
The ever-predictable NRA:


Tuesday, November 6, 2018

2018 Midterms update: House of Blues

National news outlets report Tuesday evening that the Democrats have regained majority control of the House of Representatives. GOP plans to eviscerate / "welfare-ize" (i.e. stigmatize) national health care and retirement policies will have to await another time.

Gonna be interesting going forward. Based on Trump's acrimonious Nov 7th White House Presser, expect the combative divisiveness to continue at the national level.
BREAKING: Nov 7th, President Trump has fired Attorney General Jeff Sessions.

Democrats took the House. Here’s what it means for health and medicine
By LEV FACHER @levfacher and ANDREW JOSEPH @DrewQJoseph NOVEMBER 6, 2018

ASHINGTON — Democrats rode a wave of health care messaging into a majority of the House of Representatives, projections showed Tuesday, propelled by vows to protect Americans with pre-existing health conditions and dramatically lower prescription drug costs.

Some of the winning Democrats highlighted their own health struggles. Others lambasted their Republican opponents for taking money from drug companies and health insurers. The GOP’s steadfast effort to roll back the Affordable Care Act dominated congressional campaigns around the country, and on Election Day, exit polls showed health care was the top concern for voters.

The victory puts Democrats in a far better position to test the far-reaching health care agenda they have campaigned on for well over a year, though their ambitions will almost certainly be curtailed by a Republican-held Senate and President Trump’s White House…
See also
8 burning questions for pharma, as Washington braces for a health policy shakeup
By NICHOLAS FLORKO @NicholasFlorko NOVEMBER 8, 2018
What the new Democratic House majority might actually pass on health care
House Democrats have a lot to figure out on their signature issue.
By Dylan Updated Nov 7, 2018, 10:10am EST

Health care carried House Democrats to victory on Election Day. But what now?

In interviews this fall with half a dozen senior House Democratic aides, health care lobbyists, and progressive wonks, it became clear the party is only in the nascent stages of figuring out its next steps on health care.

The new House Democratic majority knows what it opposes. They want to stop any further efforts by Republicans or the Trump administration to roll back and undermine the Affordable Care Act or overhaul Medicaid and Medicare.

But Democrats are less certain about an affirmative health care agenda. Most Democrats campaigned on protecting preexisting conditions, but the ACA has already done that. Medicare-for-all is energizing the party’s left wing, but nobody expects a single-payer bill to start moving through the House. Drug prices offer the rare opportunity for bipartisan work with Senate Republicans and the Trump White House, but it is also a difficult problem with few easy policy solutions — certainly not any silver bullet that Democrats could pull out of the box and pass on day one, or even month one, of the next Congress…
Yeah. As I've said, I've been following these issues for a long time. See my prior post and links therein.


Props to the Naked Capitalism blog.

OK, that led me to this:
Top Democrats are taking health care industry cash then opposing candidates who support “Medicare for all”
By Michael Corcoran

Seventy-five percent of Democrats support “Medicare for all.” But the American health care industry appears to have pushed Democratic leaders away from backing House candidates who would support universal public health insurance. This backhanded approach occurs as key lobbies for the industry have united in opposition to single-payer with the creation of the Partnership for America’s Health Care Future.
A new Tarbell analysis shows the health care industry as a whole is giving generously to leaders of the Democratic Congressional Campaign Committee. The DCCC describes itself as “charged with recruiting, assisting, funding, and electing Democrats” to the House. The industry includes pharmaceutical and medical device manufacturers, hospitals, nursing homes and professional health associations…



Just finished this eye-opening, jaw-dropping new book by Beth Macy.

Elegantly written, exhaustively documented, crushingly sad personal stories, reads like a compelling novel. Totally five stars.
America’s approach to its opioid problem is to rely on Battle of Dunkirk strategies—leaving the fight to well-meaning citizens, in their fishing vessels and private boats—when what’s really needed to win the war is a full-on Normandy Invasion.

Rather than puritanical platitudes, we need a new New Deal for the Drug Addicted. But the recent response has been led not by visionaries but by campaigners spewing rally-style bunk about border walls and “Just Say No,” and the appointment of an attorney general who believes the failed War on Drugs should be amped up, not scaled back. Asked in August 2017 why he hadn’t taken his own commission’s recommendation to label the epidemic a national emergency, President Trump dodged the question. He said he believed the best way to keep people from getting addicted or overdosing was by “talking to youth and telling them: No good, really bad for you in every way.”…
To be fair, the crisis had been cruelly ignored by both sides of the political aisle. The Obama administration had also been slow to address the crisis and tepid when it did. Caroline Jean Acker, the historian who is also a harm-reduction activist, told me she was scolded during a 2014 NIDA meeting for championing needle exchange and naloxone distribution after a speaker attempted to separate “good” addicts, or people who became medically addicted, from the illicit, or “bad,” users—as if there were no fluidity between the two. “The worst thing for politicians, I was told, was for them to appear they were being soft on drugs. Even under Obama, federal [Substance Abuse and Mental Health Services Administration] employees were told not to use the term ‘harm reduction,’”…

Macy, Beth. Dopesick: Dealers, Doctors, and the Drug Company that Addicted America (pp. 280-281). Little, Brown and Company. Kindle Edition.
An important read. I wrote my grad thesis 20 years ago on the topic of "The War on Drugs, and Suspicionless Drug Testing," so I tend to be reflexively skeptical with respect to politically motivated "illicit drug epidemic" hype, but this opioid abuse thing is exactly that. I have just gotten an intense, sobering education.

More to come...