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Sunday, March 17, 2013

Health data flowing "at the speed of trust"

"[I]n 2012, [Dr. Farzard] Mostashari [ONC Director] predicted interoperability and data exchange would be the 'second and more complex challenge,' following meaningful use. The emphasis, he said, will be on containing the costs and reducing the risks and liability of exchanging health data: information 'will flow at the speed of trust.'"

The Internet is a surveillance state
By Bruce Schneier, Special to CNN
updated 11:39 AM EDT, Sat March 16, 2013

...The Internet is a surveillance state. Whether we admit it to ourselves or not, and whether we like it or not, we're being tracked all the time. Google tracks us, both on its pages and on other pages it has access to. Facebook does the same; it even tracks non-Facebook users. Apple tracks us on our iPhones and iPads. One reporter used a tool called Collusion to track who was tracking him; 105 companies tracked his Internet use during one 36-hour period.

Increasingly, what we do on the Internet is being combined with other data about us ... Everything we do now involves computers, and computers produce data as a natural by-product. Everything is now being saved and correlated, and many big-data companies make money by building up intimate profiles of our lives from a variety of sources.

Facebook, for example, correlates your online behavior with your purchasing habits offline. And there's more. There's location data from your cell phone, there's a record of your movements from closed-circuit TVs.

This is ubiquitous surveillance: All of us being watched, all the time, and that data being stored forever. This is what a surveillance state looks like, and it's efficient beyond the wildest dreams of George Orwell...

Maintaining privacy on the Internet is nearly impossible. If you forget even once to enable your protections, or click on the wrong link, or type the wrong thing, and you've permanently attached your name to whatever anonymous service you're using. Monsegur slipped up once, and the FBI got him. If the director of the CIA can't maintain his privacy on the Internet, we've got no hope.

In today's world, governments and corporations are working together to keep things that way. Governments are happy to use the data corporations collect -- occasionally demanding that they collect more and save it longer -- to spy on us. And corporations are happy to buy data from governments. Together the powerful spy on the powerless, and they're not going to give up their positions of power, despite what the people want.

So, we're done. Welcome to a world where Google knows exactly what sort of porn you all like, and more about your interests than your spouse does. Welcome to a world where your cell phone company knows exactly where you are all the time. Welcome to the end of private conversations, because increasingly your conversations are conducted by e-mail, text, or social networking sites.

And welcome to a world where all of this, and everything else that you do or is done on a computer, is saved, correlated, studied, passed around from company to company without your knowledge or consent; and where the government accesses it at will without a warrant.

Welcome to an Internet without privacy, and we've ended up here with hardly a fight.

Read all of it (link in the title). What, you might ask, does that have to do health "PHI" (Protected Health Information).

Thursday, March 14, 2013
Google Fined for Intercepting Health Data, Other Information

On Tuesday, Google agreed to a multistate settlement acknowledging that it violated individuals' privacy by collecting electronic medical data and other information during its Street View mapping project, the New York Times reports.
Google will pay a $7 million fine as part of the agreement, which settles a case brought against the company by 38 states.
Details of Google's Data Collection
The case stemmed from Google's Street View mapping project, in which the company deployed specially-engineered vehicles to photograph houses and businesses on streets around the world.
The Times reports that during the Street View trips, Google also collected personal data from millions of unencrypted wireless networks (Streitfeld, New York Times, 3/12).
The information was collected between 2008 and March 2010 when a Google Street View vehicle passed by an area where information was being transmitted to or from a Web user inside a house or business (Dolmetsch, Bloomberg, 3/13).
Some of the data collected were:
  • Emails;
  • Electronic health records; and
  • Financial records.
$7 million? That'll teach 'em a lesson.

Right. Google probably spends that much every month on maseusses for their employees.

Insufficiently concerned yet? See
March 14, 2013 · by Edward Champion

Google Glass is a snazzy set of specs that will part the Red Sea if you tap it from the right angle. It aims to fuse smartphones and computers into a hands-free user experience more pleasurable than sex, religion, and world domination combined.

Glass is not yet on the market, but the news of its existence cut a hew through Mountain View with the strident fife of an unpaid piper wooing unsuspecting kids into a dark cave. It inspired Google co-founder Sergey Brin to publicly announce that he felt less male with the thick tools that came before. Some wondered why Brin didn’t just hold hard to his smartphone and slam down shots every Friday night like the rest of America. But when your net worth is $23 billion, different rules apply...

I put forth the modest proposition that Google Glass, conjured and constructed and conceived only in terms of “cool” and propped up by ostensible “journalists” who have never thought to question Mr. Brin’s brilliant PR, could pose more problems to our world than any digital invention we have seen in some time. Contrary to Mr. Brin’s suggestions, his device will not “free” us. It will quite possibly destroy several vital qualities of life we now take for granted, preying upon kind and decent and hardworking people who are still playing pickup from an economic blitzkrieg in which they had no power, little hope, and no control. One would think that a man born in Moscow under Brezhnev would grasp the cruel irony of being directly responsible for an entirely new set of encroachments upon freedom and human possibility. On the other hand, great hills of money often move mountains in other ranges...
It gives Google far more personal information than it needs to know.
According to Google’s privacy policy, this is what Google now collects from you:

  • details of how you used our service, such as your search queries
  • telephony log information like your phone number, calling-party number, forwarding numbers, time and date of calls, duration of calls, SMS routing information and types of calls
  • IP address
  • device event information such as crashes, system activity, hardware settings, browser type, browser language, the date and time of your request and referral URL
  • cookies that may uniquely identify your browser or your Google Account
  • location information
  • device information
  • any personal information you give Google (emphasis added)
Now this is just what Google gets from browsers. And this is the list that arrived just after Google changed its privacy policy in March 2012. The aim was to collect deeper information about its more than 1 billion users. There was, of course, no way to prevent Google from combining the personal data it collected through the many services offered through many devices. Much of this, of course, has been used to recalibrate advertising. But if Google has more data it can mine from you (that is, personal information that you “give” through Glass), and the Google Glass user is constantly recording her life and adding heaps of personal info that advertisers will want to know about, a Google user’s personal dossier will become highly cultivated indeed.

Google has a very poor history of sympathizing with people who don’t want their personal information shared. Forget that these users have very principled reasons for staying anonymous. But as far as Google is concerned, quiet lives don’t contribute to the hard profit line. In December 2009, then Google CEO Eric Schmidt barked to CNBC, “If you have something that you don’t want anyone to know, maybe you shouldn’t be doing it in the first place.” If this remains Google’s philosophy in 2013 (without Schmidt), then will this corporate sentiment apply to Google Glass?

We are dealing with a company that casually collects as much personal information as it can about its users without always informing them. Look no further than this FCC report from last year (PDF), which describes how Google’s Street View vehicles picked up “payload” data — that is, email, text messages, Internet usage history, and other personal information — between May 2007 and May 2010 while performing “location-based services.” Not only did Google collect 200 gigabytes of payload data between January 2008 and April 2010, but Google transferred it all to a data center in Oregon. (This privacy breach case was recently settled for the paltry sum of $7 million.)

So how much payload data will Google Glass collect? And what will the user agree to when signing up for the headset? If data limit isn’t an issue and Google employees are incapable of respecting privacy even on a subconscious level, what brave new metadata will be fed into Google’s data centers?
In December 2009, then Google CEO Eric Schmidt barked to CNBC, “If you have something that you don’t want anyone to know, maybe you shouldn’t be doing it in the first place."

Yeah, like, maybe having to have radiation therapy for prostate cancer, for for having liposuction, or a hip job, hysterectomy, stent, CABG, or just some spinal MRI's to try to determine what the hell is causing your chronic low back pain. Maybe the fact that you take statins, and Ambien, and Zoloft.

The examples you can conjure up are legion, none of them having to do with wanting to hide "bad behavior."

Maybe you should simply stop all that so Eric Schmidt, and his kindred prying, data-trafficking Suits won't be able to find out.

Read the lengthy entirety of the Champion piece. Well worth your time.

I've been probing and reflecting upon the "privacy" issues for quite some time.
...exchanging health data: information "will flow at the speed of trust." 


Well, as I reported in a prior post, I bought this book on

It's OK. Written from a nursing perspective, which is nice for me, not coming from a clinical background. But, (I'm about a third of the way through, and have skimmed through the backend stuff like the index and Glossary), it's lacking some fundamentals:

How, precisely, can you write a book about "critical thinking" and not define the word "evidence"? The book makes one passing reference to it: "...evidence (facts)..."
That is simply not true. "evidence" properly refers to "facts" -- asserted or indisputable -- that make the truth of a conclusion more likely (or, more rarely, prove it outright). Things that are "true" but nonetheless irrelevant to an issue at hand are not "evidence." That couldn't be more basic.
Beyond that oversight, guess what I'm now getting in my daily emails, repeatedly? Started within a couple of days of my ordering it.

How did they pick me up as a solicitation target (incorrectly, as it were; I'm no candidate for nursing school, either real ones or these bogus online ones)? A big mystery (LOL)., or Google, or Facebook, or someone is trafficking in my book purchases. Some algorithm somewhere is gumshoeing me.

Now, this kind of stuff is banal -- trivial, and an annoyance to me and a waste of their time. As is the snailmail "retirement opportunity" pitches I'm getting now that I've turned 67 and filed for SS (and, which looks like they're selling my info as well).

Where it goes very morally wrong is where it's creepily used behind the scenes to "redline" people for adverse credit, insurance, health care, or employment discrimination (or to do ID theft, which is the lowest of the low). Facebook has quickly become infamous for trying to "monetize" your information. They're by no means the only one.

Again, read Champion's piece.

BTW: Look at my Facebook page, and check my phone number. It's the Facebook Customer Service number. I'd like to claim that I thought that one up, but, no, someone else did. One small way to fight back. Use it.




Creativity in Medicine
How Creative Is Your Doctor?
by Danielle Ofri, New York Times

What are you doing creatively these days?

It’s not a question you hear commonly, and certainly not in a medical journal. But that was the title of a commentary in a recent issue of Academic Medicine. It caught my eye, because medicine is a field with a strong history of creativity, but its daily practice feels less and less so. Health care is being pushed steadily toward standardization, insisting on an algorithmic approach to diagnosis and treatment. Some ramifications of this trend have been beneficial, but many of these algorithms have been mechanized to the point where there is little need for human beings and their intricately personal neural networks.

Part of this stems from the way in which we are taught to think about clinical medicine. Medical school can seem like an ongoing exercise of committing lists to memory, the only creativity being the mnemonics for memorizing branches of the facial nerve or diseases with anion-gap metabolic acidosis. When students present cases, there is a sense of roteness. A patient with chest pain, for example, becomes, “Rule-out M.I. (myocardial infarction). Get an EKG, serial troponin levels, stress test, cardiology consult….”

Some of this roteness, of course, is thoroughness. You need to cover all your bases to ensure you are not missing anything serious. But rote recitation inhibits the ability to think beyond diagnostic straightjackets...

How do we teach creativity in medicine? For one thing, Dr. Kelly suggests, people’s creative sides should be brought to the forefront. She imagines water-cooler conversations and medical conferences that start by asking, “What are you doing creatively lately?” There is likely more creative talent lurking in medical professionals, and in patients, than we suspect. Bringing it forward could have a salutary effect on the medical interactions that follow.

Explicitly focusing on the creative process is the important next step. Many medical schools are beginning to incorporate arts, literature and humanities into the curricula. Critics deride this as fluff, but I think it is crucial in medical education...

If all patients and their diseases presented in exactly the manner of the textbooks, then the algorithms would be sufficient. Computers could surely do our job much more efficiently. Lord knows, they certainly wouldn’t keep misplacing their reading glasses.

But the human condition is far messier — in health and even more so in illness. Complex biology and the many overlays of social, psychological and economic issues make medicine a complicated, and nuanced, affair. The serpentine logic often seems closer to literary metaphor than to the orderly taxonomy of knowledge that we cut our teeth on.

It is our job as clinicians to work with patients to untangle these metaphors. For this, solid medical knowledge is necessary but not nearly sufficient. We need to flex the oddball neurons that connect the disparate corners of our consciousness. They need to be honed in the same manner as muscles at the gym, with ongoing stretches and workouts.

The next time you see your doctor, you might want to ask what he or she is doing creatively these days. (from The New York Times).
I'm as compulsively creative a person as you're likely to find. It just strikes me compellingly at random times, with random outcomes. I found Dr. Ofri's article (link in title) very interesting indeed.

And, how about this:
PHARMA & HEALTHCARE | 3/16/2013 @ 7:16PM |27,915 views
10 Reasons Why We Struggle With Creativity

David DiSalvo

Anyone who says “I don’t have a creative bone in my body” is seriously underestimating their skeleton.  More to the point, they are drastically undervaluing their brain.

My contention in this article is that creativity is an integral part of being human, and to deny its expression is like denying the expression of other crucial human elements that we intuitively realize we’d be miserable without. How about a life without sex, to use one bare-knuckled example? Creativity is no less a part of who and what we are. What follows are 10 reasons why we frequently struggle to get into a creative space, along with suggestions on how to get there.

1. Your brain is always putting out fires.

Cognitive science research tells us that our brains are equipped with sensitive threat-alert systems (of which the amygdala is a significant part), and these systems are older than we are, evolutionarily speaking. In our brains, the limbic system–home of the well-known fight or flight response–is ready to click on with a micro seconds’s notice. That’s a good thing. The problem is that it’s ready to click on with a micro second’s notice. As with many paradoxes within our brains, the good is also the bad depending on context...

2. Chunks of time are hard to come by.

Even when we can outwit our brain’s threat-alert system, it’s still difficult to find what the late, great management philosopher Peter Drucker advised we must find to be effective in any capacity: “chunks of time.”  Spurts of time riddled with interruptions aren’t conducive to creativity because each time our focus is wrecked, we struggle to get back to the point we’d reached in our creative “flow”...

3. The “self-efficacy” problem.
Pioneering psychologist Albert Bandura devoted a large part of his expansive career to figuring out how people can develop a necessary sense of self-efficacy–the outcome when accomplishment yields compounding confidence in one’s abilities. The irony that Bandura uncovered is that we only get there when we’ve experienced enough failure to demonstrate the difficulty of our eventual accomplishment...

Reminds me of a favorite saying: "Good judgment comes from experience, which largely comes from bad judgment."
4. The “governing scenes” problem.

Two more great psychologists, Silvan S. Tomkins and Gershen Kaufman, devoted much of their careers to figuring out why shame wields so much power in our mental lives.  Tomkins (who is the father of “Affect Theory” and “Script Theory”) coined the term “governing scripts,” and Kaufman built on his work, later coining the term “governing scenes,” which are the mental images of past experience that our brains conjure when we come across a “trigger” for that experience.

The tricky part is that our brains conjure governing scenes automatically–they arise from the unconscious. So when we experience a creative failure, our brains toss out vivid images–not just vague memories, but “scenes”–of past failures...

5. The functionary temptation.

“So, what are you going to do with that?”  Tough question to answer for anyone trying to be creative, because there probably isn’t an answer. What we seem to have a hard time getting our arms around is the fact that there also doesn’t need to be an answer.  What would a world driven by purely functionary concerns look like?  Is that a world you’d want to live in?...

6. Fear of disruption.

Getting into creative flow can disrupt your life. Henry Miller referred to this disruption in Sexus with the pregnant term “primal flux.” It’s a hard fact to handle, but the truth is that creativity isn’t all sweetness and light — it’s a volatile, disruptive force that can shatter presumptions, undermine expectations, and dismantle unquestioned standards...

7. Misunderstanding the “background noise” dimension of creativity.

For some reason we think that to be creative means constantly creating something tangible, but that’s not how creativity works.  Much of the creative process goes on in the background of your conscious mind space and emerges in conscious flurries...

8. Opportunities slip through the cracks.
You know the old story about how writers keep a notebook by their beds in case they have an idea in the middle of the night?  There’s only two things untrue about that story — it’s not just writers who do it (or at least it’s not just writers who should do it) and it’s not just in the middle of the night that a notebook or something to scribble on is invaluable to capture rapidly evaporating thoughts.

9. It’s easier to get numb.

Irony of ironies, the same incredible organ in our heads that allows us to be creative is also perilously prone to brain-numbing distractions. Sure, those can be chemical distractions–drugs, alcohol, etc–but in this case I mean just the regular old “plug-in drugs” like TV (using the term coined by author Marie Winn).  The problem with TV, of course, isn’t TV, it’s the hours upon hours that it draws us in...

10. Limited exposure to the creativity of others.
I’m a firm believer that creative inspiration isn’t all about originality; it’s more about being driven by the creative achievements of others. After reading a great novel, creative energy swirls in the brain like a newly spawned tornado. After watching an incredible movie, mental wormholes open to challenging ideas and possibilities. Same goes for museums and galleries and concerts and even electronics shows. It doesn’t matter where the ideas originate — it matters where they take you...
Indeed. Problematic for today's "productivity treadmill" captive clinical practitioners, no?

Another resource, a favorite book of mine, Steven Pressfield's glorious "The War of Art."

What keeps so many of us from doing what we long to do? Why is there a naysayer within? How can we avoid the roadblocks of any creative endeavor—be it starting up a dream business venture, writing a novel, or painting a masterpiece?

The War of Art identifies the enemy that every one of us must face, outlines a battle plan to conquer this internal foe, then pinpoints just how to achieve the greatest success.

The War of Art emphasizes the resolve needed to recognize and overcome the obstacles of ambition and then effectively shows how to reach the highest level of creative discipline. Think of it as tough love...for yourself.
Excerpt from the excerpts
1. WHAT I DOI get up, take a shower, have breakfast. I read the paper, brush my teeth. If I have phone calls to make, I make them. I've got my coffee now. I put on my lucky work boots and stitch up the lucky laces that my niece Meredith gave me. I head back to my office, crank up the computer. My lucky hooded sweatshirt is draped over the chair, with the lucky charm I got from a gypsy in Saintes-Maries-de-la-Mer for only eight bucks in francs, and my lucky LARGO name tag that came from a dream I once had. I put it on. On my thesaurus is my lucky cannon that my friend Bob Versandi gave me from Morro Castle, Cuba. I point it toward my chair, so it can fire inspiration into me. I say my prayer, which is the Invocation of the Muse from Homer's Odyssey, translation by T.E. Lawrence, Lawrence of Arabia, that my dear mate Paul Rink gave me and which sits near my shelf with the cuff links that belonged to my father and my lucky acorn from the battlefield at Thermopylae. It's about ten-thirty now. I sit down and plunge in. When I start making typos, I know I'm getting tired. That's four hours or so. I've hit the point of diminishing returns. I wrap for the day. Copy whatever I've done to disk and stash the disk in the glove compartment of my truck in case there's a fire and I have to run for it. I power down. It's three, three-thirty. The office is closed. How many pages have I produced? I don't care. Are they any good? I don't even think about it. All that matters is I've put in my time and hit it with all I've got. All that counts is that, for this day, for this session, I have overcome Resistance.


I recall from back when I lived in Knoxville always seeing this billboard while coming up toward the South Knoxville bridge on Chapman Highway, one exuberantly extolling some local restaurant as "The New Dining Tradition."

Fast forward a quarter century.

"The new standard of care"? Via which certifying authorities? Via what empirical outcomes evidence?

This is what you get when you have Gen Y'ers with B.A.'s in Advertising writing ad copy.

You just summarily declare yourself to be a "new standard"?


This Ol' Dawg ain't buyin' it.

Where Will the Clinical Faculty Come From?
James E. Lewis, PhD

Everyone, it seems, agrees that many more physicians are needed over the next 20 to 30 years to respond to more, older Americans, physician retirements and deaths, reduced doctor work hours, and other factors. Both new medical schools and expanded enrollments in existing medical schools are being pursued as ways to increase the physician workforce by 30 percent at minimum. The question is, where is academic medicine going to find the additional faculty to teach more students, and how does that number affect physician workforce calculations and projections? My analysis suggests that question is both critical and lacking attention...
Great post. Large looming problem. Below, from FutureDocs, apropos of medical ed:
What Can the Unmatched Seniors Tell Us?

Yesterday, after the mayhem and jubilation of celebrating a successful match at the Pritzker School of Medicine with our students, I went onto Twitter to follow the #match2013 hashtag to understand what the reactions were.  Most were positive, but one headline caught my attention ‘In Record-Setting ‘Match Day,’ 1,100 Medical Students Don’t Find Residencies.”

It is true this was the largest match because it was “All-in” – programs either were in the match for all their positions (including international medical graduates or IMGs) or they were not.  Obviously, many programs put more positions up for grabs in the Match.  After I reposted this article to Twitter, there were many theories and questions about who these unmatched students were and why...

More to come...

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