The 300

So, in my last post, I linked to an article "10 great reasons to have a blog." I give you my 300.

Maybe I should just declare "victory" and go home. ;) No one pays me to write this blog (nor will I crap it up with click-thru ads), and I'm now nominally "retired."

The major issues remain as they have pretty much been since I started: Health IT usability ("UX"), (relatedly) workflow, (also relatedly) interoperability, "analytics" (including the "Big Data" cliche), privacy and security, and practice sustainability during a period of major policy reform driven in large measure by the controversial PPACA.

Close on the heels of the foregoing are dynamic issues relating to "mobile health" -- BYOD policies ("Bring Your Own Device," mostly with respect to the security implications), personal fitness tracking, i.e., "quantified self" apps, and the socioeconomic determinants of health -- a particular concern of mine of late, given that all of these cool techno toys and process reforms will come to naught if most people still cannot afford health care.

The IHI Triple Aim

See my post of 5 days ago "Medical bridges to nowhere?" In particular,

NQF: "Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors" (draft NQF report)

Risk adjustment—statistical methods to account for patient-related factors when computing outcome measures—is used to make more accurate evaluations about quality of care. NQF’s current policy recommends the adjustment of outcome measures for clinical factors, such as severity of illness and co- morbidities, recognizing that patients who are sicker and have multiple conditions have a higher likelihood of worse outcomes, regardless of the quality of care provided.

Increasingly, policymakers and other leaders have raised the question of whether performance measures used in accountability applications, including public reporting and pay-for-performance, should be adjusted for sociodemographic factors in order to improve the accuracy of performance results. There is a substantial body of evidence that sociodemographic factors influence a variety of patient outcomes and some processes...

Add one book book to my exigent reading stash. I got this for my Kindle, and read it straight through yesterday. A compelling read, a bit of a different perspective on IT.

ALTHOUGH INEQUALITY OF INCOME AND WEALTH IN AMERICA HAS been growing steadily for the past forty years, it was with the Wall Street crash of 2007– 2008 that this disparity took on lurid, visible form with the contrasting fortunes of the winners and losers. On the winning side, with their big bonuses, were many Wall Streeters who themselves bore responsibility for the crash. On the losing side were victims of the crash on Main Street, burdened with high unemployment, crushing personal debt, falling real wages, and shrinking personal wealth propelled by housing foreclosures.

By grim coincidence, detailed statistical evidence of how extreme American inequality had become also appeared during the crisis year of 2007. The data revealed the great good fortune of the super rich— of the richest 1 percent, 0.1 percent, and even the richest 0.01 percent of Americans. The share of total income of the top 1 percent rose from 8 percent in 1974 to 18 percent in 2007 and from 9 percent to 23.5 percent if capital gains and income from investments were included. The equivalent share of the richest 0.1 percent of Americans rose from 2.7 to 12.3 percent and the share of the very richest, the top 0.01 percent, from less than 1 percent to 6 percent during the same period.

The reverse side of this massive concentration of income and wealth at the earnings pinnacle— unprecedented since the pre-1914 Gilded Age— is the stagnation or fall in the real incomes of virtually everybody else. The growth of median annual earnings of most Americans has been spectacularly weak, irrespective of educational attainment. Between 1980 and 2006 the median annual earnings of fully employed entry-level workers between the ages of twenty-five and thirty-four with a bachelor’s degree or higher increased by just $ 1,000 in constant 2006 dollars, from $ 44,000 to $ 45,000, for a total percentage increase of just 2.27 percent over a twenty-six-year period, or an increase of less than 0.1 percent a year. The real earnings of those with some college education but with less than a four-year bachelor’s degree fell by $ 5,300 over the same period, or a percentage fall of 14.5 percent. For those with a high school diploma or equivalent, the comparable figure was a fall of $ 5,200 in constant dollars, for a total percentage fall of 15.3 percent.

 Unless soon reversed, these decades of income stagnation or decline for the majority threaten something fundamental to American identity that for more than two centuries has set the United States apart from its old European mother countries: the confidence of most Americans that through education and hard work, they can overcome the barriers of birth and inheritance and rise as far as their talents will take them. This confidence is draining away as the barriers of American class strengthen, shrinking the life prospects of what may now be a majority of Americans and including much of the middle class among the newly disadvantaged.

As its title suggests, this book will look at the role of information technology (IT) as a driver of this inequality. By making us dumber, smart machines also diminish our earning power. But the machines that do this are not the automating, stand-alone machine tools of the 1950s, or even the stand-alone mainframes of the 1960s and 1970s, but vast networks of computers joined by software systems and the Internet, with the power to manage the affairs of giant global corporations and to drill down and micromanage the work of their single employees or teams of employees. There now exist in the US economy of the new century these very powerful agents of industrialization, known as Computer Business Systems (CBSs), that bring the disciplines of industrialism to an economic space that extends far beyond the factories and construction sites of the industrial economy of the machine age: to wholesale and retail, financial services, secondary and higher education, health care, “customer relations management” and “human resource management (HRM),” public administration, corporate management at all levels save the highest, and even the fighting of America’s wars.

CBSs are being pushed by business academics, especially at the Massachusetts Institute of Technology (MIT), management consultants such as Accenture and Gartner, and IT companies such as SAP, IBM, and Oracle, and embraced by corporations for their efficiency. But they are not well understood beyond these specialist communities engaged in their creation, marketing, and servicing. These systems are today rather as black holes once were before black holes were fully discovered. Astrophysicists knew that there were things out there in the cosmos exerting a gigantic gravitational pull over everything that came into contact with them, but they did not yet know exactly what these things were. CBSs are the semidiscovered black holes of the contemporary economy...

Head, Simon (2014-02-11). Mindless: Why Smarter Machines are Making Dumber Humans (pp. 2-3). Basic Books. Kindle Edition.

Highly recommended. The book comprises a motherload of relevant insights, including scathing, documented detail concerning the utterly odious treatment of employees at Walmart and Amazon.

An excerpt from the concluding pages:

In this CBS world concepts such as empowerment and skill no longer mean what they once did. To be skilled and empowered is to be in a state of perfect, frictionless harmony with the system, in perfect conformity with its rules and commands. Because experience and wisdom reside in the system and not in those who use it, the experience that users accumulate over time does not make them any more valuable to the system. Indeed, the contrary is true, because older workers may become wedded to past practices of the system that are now obsolete. These veterans can and should be fired and replaced by younger workers who can be paid less and have no crusty attachments to past practices...

By relying on information technology both to accelerate the processes of business output and to diminish the role of labor in production, along with its earning power, the new digital industrialism has overlooked the identity between producers and consumers, ignoring the wisdom of Henry Ford when he introduced the five-dollar day at his Detroit plants in 1914. Ford saw that his workers needed to be well paid in order to afford the Model Ts rolling off the line at the Highland Park plant. In contrast, the earnings malaise of today’s US producers is now spilling over into their lives as consumers, after years of putting off the evil hour with recourse to debt. With American consumers providing 75 percent of the economy’s final demand, this is a serious blow to the economy’s growth prospects, a leading cause of the weak recovery from the Great Recession, and a reason the Fed has had to keep interest rates so low and for so long. What is to be done? Before looking for answers, it is worth taking stock of the headwinds most Americans face, judged by the statistics for the long-term stagnation or decline of their real earnings: first, their employment in workplaces that do not make full use of their skills and subject them to intrusive systems of monitoring and control; second, the stagnation or shrinkage of their real earnings, related directly to this deskilling; third, their need to shoulder increasing health care and pension costs, dumped on them by employers; and fourth, the growing insecurity of the workplace, linked to outsourcing, globalization, and a corporate readiness to have early recourse to layoffs. 2 These are not the acts of a corporate leadership that values the skills and loyalty of its workforce and wants to strengthen these ties over time. These are indeed the claims of countless corporate mission statements, but the record reveals a preference for harsh cost-cutting strategies in which high employee turnover and high employee cynicism can be offset by system expertise and with the system’s control mechanisms ensuring that employees act as the systems prescribe... (p. 189).

If a clear majority of Americans are losing out in today’s economy, as they are, the political task is to create a dominant coalition from among them that would include low-income minorities and whites of the Walmart and Amazon world, middle managers and middle administrators whose real incomes have been steadily eroding, and even nonelite professionals of the nonconcierge economy suffering the same fate. The political debate is central, and it should be very much part of this debate that the progressive critique of the economy include the issues of white-collar industrialism discussed here.

The progressive response to the harshness of nineteenth-century capitalism was fueled by a growing awareness of what was going on behind factory walls. CBSs are by comparison invisible, and they benefit from this obscurity. This needs to end, and this books is a modest step in that direction. Yet there are grounds for optimism. The future contours of the economic debate are fluid because the future course of the economy itself is fluid. With its failure to reward the majority of Americans, the economy’s present course is unsustainable, and as this becomes more and more apparent, volatility will spill over to the public debate and open it up.

In macroeconomics this unsustainability goes beyond the preoccupation with public spending and the public debt, currently the number-one concern in Washington. It is bound up with the difficulty of achieving strong, sustained growth as long as consumer-producers are in eclipse, blunting what was once the economy’s most reliable source of demand and making the tasks of deficit reduction immeasurably harder. But the politics of the wounded producer-consumer is a whirlpool of volatility (p. 193).

Having had a nano-particle role in and insider view of the 2000's subprime mess, I cannot but be drawn to these kinds of works. More broadly, I've been following financial frauds since the Equity Funding Life scandal of the 1960's. We never seem to learn.

Just a bit of my reading list in this area:

• The Equity Funding Life scandal 
• Predator's Ball
• Barbarians at the Gates 
• The Best Way to Rob a Bank is to Own One 
• Liar's Poker 
• The Money Culture 
• This Time is Different 
• Debt: the first 5,000 years 
• Law's Order 
• Moral Tribes 
• Predator Nation 
• Econned 
• It Takes a Pillage 
• Conspiracy of Fools 
• The Smartest Guys in the Room 
• Moral Markets 
• LesterLand 
• It's Even Worse Than It Looks
• A Fresh Look at Greed
• The Big Short 
• Boomerang 
• Bailout 
• The Lost Bank 
• Seven Sins of Wall Street 
• The Flash Boys 
• Mindless

Again, as it goes to health IT and healthcare, the health of our people is in large measure inextricably correlated with the health of our physical environment, our culture, and our economy. Psychosocially toxic healthcare workplaces (the patient safety inimical "bully culture," "productivity treadmill"), toxic physical environments (ranging from localized chemical spills to global warming), and a toxic, unjust, and unsustainable economy all work to frustrate or negate our technological and clinical improvement efforts. We could end up with yet another iteration of "Rescuer-Victim-Persecutor" syndrome. "See How Hard We Tried?"
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U.S. SPENDING PRIORITIES IN ONE GRAPH

The price of policing the world.

Many other nations have significantly more to spend on social services (including more effective health care) and their economies more broadly because they've in essence outsourced defense spending to us.

"OBAMACARE" ERRATUM

OK, this is funny.

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More to come...