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Monday, September 29, 2014

More Health 2.0 2014 reflections: On Technology, Innovation, and Market Competition

Let me first re-post something I'd put up earlier.

If It Looks Like A Bubble, And Quacks Like A Bubble ...
Todd Hixon, Forbes

Then it’s best not to build your house on it. Silicon Valley sure looks like a bubble to me, and many others think so too. While these are heady times, it’s actually very difficult to start new investments. Some back-to-basics thinking is the best way to mitigate the risk.

I spent several days at a conference in Silicon Valley recently and then visited venture capital friends on Sand Hill Road. The venture capital market there is dramatically different from the rest of the U.S., even New York, which is having a good run...

At the Health 2.0 conference, which I attended, there was much moxie on display, including a digital health wearables fashion show complete with a runway and a custom music mix. I heard comments, however, that digital health investors are starting to see a lot of me-too offerings: if you closed your eyes and walked 100 feet, you’d bump into three companies selling systems to reduce hospital re-admissions.

Many VCs are wondering, how do you invest into this market with a decent chance of success? If you are chasing the companies that have visibly achieved “escape velocity” in their markets, you are competing with the great names and greater check books. Only a handful can succeed in that game. And then you pay a price based on perfection and bet on continuation of aggressive growth financings and a hot IPO market.

If you play at the seed level, you compete with the host of angels, accept weak terms, and invest in companies in which entrepreneurs may be on their own because seed investors often can’t help, don’t spend the time, or lack governance levers when the going gets tough. And occasionally the big funds reach down and take over an early financing with a big check at a high price, squeezing other investors out. One VC blogger calls this a “piggy round”.

Burn rates are running $500k to $1 million per month and up, in many cases (more). This presumes the ability to keep financing on favorable terms. If not, the blood quickly gets ankle-deep.

This market dynamic looks delicate to me. While the Internet continues to grow and entrepreneurs keep finding new opportunities, the sources of money fueling much of the boom are fickle. The scope of the hot segments market is narrow: largely confined to Silicon Valley and a half-dozen sectors. If the end comes fast, many companies will quickly be in mortal jeopardy: burn rates, valuations, and capital structures will be crushed...
Ouch. "[I]f you closed your eyes and walked 100 feet, you’d bump into three companies selling systems to reduce hospital re-admissions."

How much Built-to-Flip VC stuff is going on in health tech? What of the economics of all this? Couple of Connecting-Some-Dots items. First, also from Forbes:
Is Strategy Dead? 7 Reasons The Answer May Be Yes
Rick Smith

I am an ex-strategy consultant. I have an MBA. And I am increasingly convinced the relevancy of both has been permanently diminished. Is strategy dead?

Webster’s defines Strategy as “a careful plan for achieving a particular goal over a long period of time.” Yet today, what constitutes a long period of time? 10 years? Or 9 months?! Well thought out plans, or even the objectives that they are built around seem destined to be revisited every one or two quarters. And those who are careful are increasingly vulnerable to those who are agile.

However you debate the semantics, there are several major shifts that have occurred which are rapidly diminishing the relevance of business strategy and strategic planning:

Incrementalism has been disrupted by disruption.
Innovation in most organizations can best be described as “trained incrementalism.” Managers throw buzzwords around like “out of the box thinking” and “paradigm shifts”, but when pressed to deliver, quickly retrench and focus on efforts that are merely incremental. Generating 1-2% improvements is like lining up sandbags in front of an impending tsunami. Someone please show me a single Taxi company strategic plan that anticipated Uber virtually wiping out a century-old industry. 

Disruption is coming to a company near you.
Most organizations are not prepared for this, or even preparing for it.

Innovation is occurring with high variance outcomes. Traditionally, a strategic risk assessment goes something like this; identify the four most likely competitive or market outcomes, and create a plan for each. The beloved 2×2 matrix to the rescue! But innovations today are not shaking up market share, they are creating and destroying markets entirely. Peering into the future, there are simply far too many possible outcomes to anticipate, let alone plan for comprehensively.

The past is no longer a good predictor of the future.
Company behavior has changed: the average life expectancy of a Fortune 500 company has dropped from more than 80 years to less than 15 in the last century. Consumer behavior has changed: the aging baby-boomers are not acting like the elderly of previous generations. Babies today leave the hospital with a blanket, an iPhone, a Facebook page and a Twitter handle. #OMG. If we do not study history, we are doomed to repeat it. Unless, of course, history stops repeating altogether.

Competitive lines have dissolved completely.
Start-ups are successfully competing with established technology companies are competing with product companies are competing with big data companies. Strategists have long benefited from organized, narrow views of competitive sectors, highlighting the strengths and weaknesses of a discrete group of companies.

Yet this approach is increasingly myopic. Monday’s competition may likely come from a known competitor in your defined segment. Friday, you will be disrupted by a company from a sector you never even saw coming.

Information has gone from scarcity to abundancy.

Much of the value of strategy planning and consulting has been derived from the possession of scarcely available information. But today, information is abundant. Knowledge is transparent. The critical organizational need has shifted from identifying scarce information to quickly assimilating mass information and deftly acting upon it.

It is very difficult to forecast option values. 

Let’s say a company wants to open a new factory. Strategists detail the expected costs and revenues, and determine if the project is worth the investment. But how do you forecast the Internet of Things? How much will Big Data cost you, or be worth?
Nothing? Or so much that your organization becomes irrelevant? At this point, the actual outcomes of these investments are wild guesses at best. Yet most companies are anteing up – afraid that the price of sitting on the sidelines may be catastrophic. Everyone seems to be stepping on the gas despite the headlights growing increasingly dim.

Large scale execution is trumped by rapid transactional learning.

Need to trim $1 billion in expenditures? Launch a massive Six Sigma project across the entire organization over a five year period, and the results are fairly predictable. Ah, the good ole’ days! Unfortunately, today’s leaders do not have the luxury of executing a prescribed strategy over a long period of time. Rather, they must build a pervasive capability of rapid transactional learning. Assimilate what is changing quickly. Push decision making toward the customer. Today’s game of business looks a lot less like Chess, and a lot more like hockey. Don’t worry about planning four or five moves out, just get quickly to where the puck is going. Sorry, there are no timeouts.

In the end, your company’s strategy is nothing more than the collective actions of all of your employees, and these actions are being guided less by strategies thoughtfully crafted within wood paneled conference rooms, and more by speed, unpredictability and sweeping change occurring on a dynamically evolving battlefield.

The language of Strategy may be alive and well within the musings of corporate planners and external consultants.

Unfortunately, the marketplace is no longer paying attention.
OK, drum roll... Some of the following may well seem absurdly heretical and counterintuitive, but you really need to read the entire book. When I saw this touted by Nicholas Nassim Taleb, I just had to get it. Wonderfully written and argued.

CREATIVE MONOPOLY means new products that benefit everybody and sustainable profits for the creator. Competition means no profits for anybody, no meaningful differentiation, and a struggle for survival. So why do people believe that competition is healthy? The answer is that competition is not just an economic concept or a simple inconvenience that individuals and companies must deal with in the marketplace. More than anything else, competition is an ideology— the ideology— that pervades our society and distorts our thinking. We preach competition, internalize its necessity, and enact its commandments; and as a result, we trap ourselves within it—even though the more we compete, the less we gain.

This is a simple truth, but we’ve all been trained to ignore it...


The competitive ecosystem pushes people toward ruthlessness or death.
A monopoly like Google is different. Since it doesn’t have to worry about competing with anyone, it has wider latitude to care about its workers, its products, and its impact on the wider world. Google’s motto—“ Don’t be evil”— is in part a branding ploy, but it’s also characteristic of a kind of business that’s successful enough to take ethics seriously without jeopardizing its own existence. In business, money is either an important thing or it is everything. Monopolists can afford to think about things other than making money; non-monopolists can’t. In perfect competition, a business is so focused on today’s margins that it can’t possibly plan for a long-term future. Only one thing can allow a business to transcend the daily brute struggle for survival: monopoly profits.

So, a monopoly is good for everyone on the inside, but what about everyone on the outside? Do outsized profits come at the expense of the rest of society? Actually, yes: profits come out of customers’ wallets, and monopolies deserve their bad reputation— but only in a world where nothing changes.

In a static world, a monopolist is just a rent collector. If you corner the market for something, you can jack up the price; others will have no choice but to buy from you. Think of the famous board game: deeds are shuffled around from player to player, but the board never changes. There’s no way to win by inventing a better kind of real estate development. The relative values of the properties are fixed for all time, so all you can do is try to buy them up.
But the world we live in is dynamic: it’s possible to invent new and better things. Creative monopolists give customers more choices by adding entirely new categories of abundance to the world. Creative monopolies aren’t just good for the rest of society; they’re powerful engines for making it better.

Even the government knows this: that’s why one of its departments works hard to create monopolies (by granting patents to new inventions) even though another part hunts them down (by prosecuting antitrust cases). It’s possible to question whether anyone should really be awarded a legally enforceable monopoly simply for having been the first to think of something like a mobile software design. But it’s clear that something like Apple’s monopoly profits from designing, producing, and marketing the iPhone were the reward for creating greater abundance, not artificial scarcity: customers were happy to finally have the choice of paying high prices to get a smartphone that actually works.

The dynamism of new monopolies itself explains why old monopolies don’t strangle innovation. With Apple’s iOS at the forefront, the rise of mobile computing has dramatically reduced Microsoft’s decades-long operating system dominance. Before that, IBM’s hardware monopoly of the ’60s and ’70s was overtaken by Microsoft’s software monopoly. AT& T had a monopoly on telephone service for most of the 20th century, but now anyone can get a cheap cell phone plan from any number of providers. If the tendency of monopoly businesses were to hold back progress, they would be dangerous and we’d be right to oppose them. But the history of progress is a history of better monopoly businesses replacing incumbents.

Monopolies drive progress because the promise of years or even decades of monopoly profits provides a powerful incentive to innovate. Then monopolies can keep innovating because profits enable them to make the long-term plans and to finance the ambitious research projects that firms locked in competition can’t dream of.
So why are economists obsessed with competition as an ideal state? It’s a relic of history. Economists copied their mathematics from the work of 19th-century physicists: they see individuals and businesses as interchangeable atoms, not as unique creators. Their theories describe an equilibrium state of perfect competition because that’s what’s easy to model, not because it represents the best of business. But it’s worth recalling that the long-run equilibrium predicted by 19th-century physics was a state in which all energy is evenly distributed and everything comes to rest— also known as the heat death of the universe.

Whatever your views on thermodynamics , it’s a powerful metaphor: in business, equilibrium means stasis, and stasis means death. If your industry is in a competitive equilibrium, the death of your business won’t matter to the world; some other undifferentiated competitor will always be ready to take your place.
Perfect equilibrium may describe the void that is most of the universe. It may even characterize many businesses. But every new creation takes place far from equilibrium. In the real world outside economic theory, every business is successful exactly to the extent that it does something others cannot. Monopoly is therefore not a pathology or an exception. Monopoly is the condition of every successful business.

Tolstoy opens Anna Karenina by observing: “All happy families are alike; each unhappy family is unhappy in its own way.” Business is the opposite. All happy companies are different: each one earns a monopoly by solving a unique problem. All failed companies are the same: they failed to escape competition.

New technology tends to come from new ventures— startups. From the Founding Fathers in politics to the Royal Society in science to Fairchild Semiconductor’s “traitorous eight” in business, small groups of people bound together by a sense of mission have changed the world for the better. The easiest explanation for this is negative: it’s hard to develop new things in big organizations, and it’s even harder to do it by yourself . Bureaucratic hierarchies move slowly, and entrenched interests shy away from risk. In the most dysfunctional organizations, signaling that work is being done becomes a better strategy for career advancement than actually doing work (if this describes your company, you should quit now). At the other extreme, a lone genius might create a classic work of art or literature , but he could never create an entire industry. Startups operate on the principle that you need to work with other people to get stuff done, but you also need to stay small enough so that you actually can.

Positively defined, a startup is the largest group of people you can convince of a plan to build a different future. A new company’s most important strength is new thinking: even more important than nimbleness, small size affords space to think. This book is about the questions you must ask and answer to succeed in the business of doing new things: what follows is not a manual or a record of knowledge but an exercise in thinking. Because that is what a startup has to do: question received ideas and rethink business from scratch...
Thiel, Peter; Masters, Blake (2014-09-16). Zero to One: Notes on Startups, or How to Build the Future (Kindle Locations 129-411). Crown Publishing Group. Kindle Edition
Bracing. Get a copy. While every page is a delight, read the conclusion in particular.

apropos of healthcare business models, got this on my Atlantic iPhone app:

The Rise of the M.D./M.B.A. Degree
At a time when many of healthcare's greatest challenges are business problems, more and more doctors are adding three extra letters after their names.

For David Gellis, the spark came during a class in college on health policy in America. He had known he wanted to become a doctor, but he was looking for a way to contribute to systemic change in healthcare. His professor at the time was Donald Berwick, who later headed the Center for Medicaid and Medicare Services and made a bid this year to be the Democratic candidate for governor of Massachusetts on a platform that includes single payer healthcare. Berwick’s class inspired Gellis to think more about the business skills needed in healthcare.

Gellis decided he wanted to apply business skills specifically to primary care, and he applied to Harvard Medical School and Harvard Business School simultaneously. By the time he began his residency in internal medicine, he’d completed both degrees and had caught the attention of Iora Health, an innovative primary care practice that was planning to start up in a few cities around the country. When he finished his residency three years later, the company hired him as a primary care provider. Half a year later, he is helping to lead their Brooklyn practice.

“I have an actual management title and responsibilities, which is pretty crazy six months out of residency,” said Gellis.

According to Maria Chandler, who is president of the Association of M.D./M.B.A. Programs and herself a recipient of both degrees, the degree combination “fast tracks” graduates up the career ladder. The current nominee for surgeon general, Vivek Murthy, holds both degrees, has founded multiple organizations, and is only 36 years old.

Those with dual degrees have a particular edge when it comes to hospital administration, a field that has traditionally employed M.B.A.s as leaders and M.D.s as middle managers. According to a New York Times analysis in May, the average annual salary for a hospital administrator is $237,000, compared with an average of $185,000 for a clinical physician. A 2011 study found that hospitals with physician CEOs outperformed those with non-medical leadership.

“Just like you wouldn’t want a school superintendent to never have taught, you don’t want the person leading your hospital to never have taken care of a patient,” said Vinod Nambudiri, a fifth-year internal medicine and dermatology resident at BWH and a graduate of Harvard’s joint M.D./M.B.A. program. Chandler wonders how physicians can become administrators without business training. “What industry puts somebody with no business training in front of a huge budget?” said Chandler. “Nowhere but medicine, really.”...
Interesting article. I am no big fan of the MBA degree (I once irascibly called it "a short bus degree for people who can't write a Thesis"). The fact that U.S. healthcare is such a byzantine, expensive mess is to a significant degree the doing of MBA thinking.

During my credit risk management days, I worked in a department full of them. We had one econometrician, two statisticians (one of whom, my underachiever bud Ezra, also had an MBA and two undergrad degrees), me, the liberal arts "Ethics" guy, and about 10 MBAs. Our MBAs were smart, collegial people, but they typically had a relatively narrow paradigimatic focus.

For many years, researchers and industry observers have conjectured that rising generic penetration might have an impact on the rate and direction of pharmaceutical innovation. Using a new combination of data sets, we are able to estimate the effects of rising generic penetration on early-stage pharmaceutical innovation. While the overall level of early-stage drug development has continued to increase, generics have had a statistically and economically significant impact on where that development activity is concentrated and how it is done. In the full sample, we find that, as our baseline measure of generic penetration increases by 10% within a therapeutic market, we observe a decrease of 7.9% in early-stage innovation in that market. This implies that drug development activity is moving out of markets where generic competition is increasing and into domains where it is relatively less intense.
From The Incidental Economist.

Science is complicated. Simple concepts that appear at first to be obviously true or untrue usually turn out to be more nuanced than we thought.  Newtonian physics was taken as “the truth” until we learned in the 20th century that it didn’t apply on cosmological or subatomic scales. Medicine and human physiology are more complicated than most people realize or want to believe.
From Science Based Medicine.
...I spoke with one of the best statisticians at Harvard, Alan Zaslavsky, about the case. This is why we need to adjust quality measures for socioeconomic status (SES), he said. I’m worried, I said. Hospitals shouldn’t get credit for providing bad care to poor patients. Mr. Jones had a real readmission – and the hospital should own up to it. Adjusting for SES, I worried, might create a lower standard of care for poor patients and thus, create the “soft bigotry of low expectations” that perpetuates disparities.
From THCB, Changing My Mind on SES Risk Adjustment 


More to come...

Saturday, September 27, 2014

Back down in the Weeds': A Complex Systems Science Approach to Healthcare Costs and Quality

There is a mounting crisis in delivering affordable healthcare in the US. For decades, key decision makers in the public and private sectors have considered cost-effectiveness in healthcare a top priority. Their actions have focused on putting a limit on fees, services, or care options. However, they have met with limited success as costs have increased rapidly while the quality isn’t commensurate with the high costs. A new approach is needed. Here we provide eight scientifically-based steps for improving the healthcare system. The core of the approach is promoting the best use of resources by matching the people and organization to the tasks they are good at, and providing the right incentive structure. Harnessing costs need not mean sacrificing quality. Quality service and low costs can be achieved by making sure the right people and the right organizations deliver services. As an example, the frequent use of emergency rooms for non-emergency care demonstrates the waste of resources of highly capable individuals and facilities resulting in high costs and ineffective care. Neither free markets nor managed care guarantees the best use of resources. A different oversight system is needed to promote the right incentives. Unlike managed care, effective oversight must not interfere with the performance of care. Otherwise, cost control only makes care more cumbersome. The eight steps we propose are designed to dramatically improve the effectiveness of the healthcare system, both for those who receive services and those who provide them.

The US healthcare system suffers from high costs and low quality compared to healthcare systems internationally, as measured by reported life expectancy [4] and infant mortality. High rates of nosocomial infection (infections acquired in healthcare settings) as well as adverse drug effects (errors in the administration of medication) manifest the need for improvement in the system of care. At a cost of $2.5 trillion annually [6] the system is not delivering affordable, effective care. The paradox of higher costs and lower quality makes clear the existence of a systemic problem. How can we fix it? Complex systems science provides tools to address this question directly. In this paper we provide eight scientifically based steps toward reducing costs and improving quality. Our suggestions arise from an analysis of the US healthcare system in particular, but they are broadly applicable when adapted appropriately.

The eight steps are:

1. Separate simple care from complex care.
2. Empower workgroup competition as an incentive, and avoid regulating costs or quality.
3. Create superdoctor teams to rapidly diagnose and treat highly complex conditions.
4. Accelerate intake routing to rapidly identify the right provider.
5. Add redundancy to improve communication to prevent prescription errors.
6. Create disinfection gateways at spatial boundaries to reduce hospital-based infections.
7. Use e-records for research to supplement clinical studies.
8. Promote “First Day” celebrations to encourage healthy behavior...



Scientific principle—“Big data” research: Our increasingly complex world yields massive quantities of data, and we now have the scientific knowledge to perform pattern recognition on the data. Scientists are utilizing such “big data” methods in areas as diverse as genomics, finance, and crime prevention. If made available, the vast corpus of medical records should result in the discovery of opportunities for advancement in medicine. This approach complements the more traditional and more controlled framework of specially designed clinical trials.
Electronic records, which have become increasingly prevalent in recent years, represent a valuable repository of medical data. There are over 300 million people in the United States, most of whom are receiving some sort of medical care. If anonymized medical records were made available to researchers, these e-records could be leveraged to improve care at low cost.
In today’s quest to answer questions about medicine and human health, the large-scale, controlled clinical trial is central. New drugs, surgical techniques, non-surgical interventions and medical devices are typically tested in such studies, which require the creation of control and test groups, controlling for confounding factors such as age and lifestyle, and the tracking of patients...
[S]ince each person’s medical records may cover many years, we can learn about long term effects much more easily and cost-effectively by analyzing these available data than by conducting longitudinal studies on a particular therapy. Thus, we can use these data to discover long-term effects that may otherwise not be detected at all. Leveraging the availability of care data to increase our knowledge can’t and shouldn’t replace controlled studies or physician experience. But it can be a powerful and cost-effective tool, allowing us to utilize huge amounts of information and new methods of analysis to increase our medical knowledge, improving our ability to treat patients and take care of ourselves...
Interesting paper (pdf, 47 pages). Arguing CER in the foregoing, essentially.

A hundred years ago, physicians were generalists, treating most medical conditions. Humanity didn’t have nearly as much medical knowledge and knowhow back then so that for the most part a single doctor could master what was known. That has changed

Medical knowledge now far exceeds a single expert’s ability to master it. Medical students receive a general training and then they specialize, seeking to learn just one small piece of what we know about medicine.

Specialists have become essential because of the complexity of care. The more we learn, the more kinds of specialists are needed. Increasingly, however, it is necessary to have patients see multiple specialists for a single problem, which causes fragmentation and delays the care. Furthermore—and critically—the interplay between multiple causes of a single condition, or multiple aspects of its treatment, makes it difficult for the separated specialists to address such complex problems. 

What is the solution? 

A human being is a single working system and specialists must be able to work together as an integrated unit for diagnosis and treatment. Specially constituted teams of physicians and other care providers who work together on a regular basis should address the more complex problems. The cost of having such a team in place might seem high, but for complex cases such a team will prove to be more effective and less costly than the alternative—the difficulties, delays, and costs inherent in multiple appointments. The challenge is making sure the teams can work together smoothly and efficiently, and with better results than specialists working separately.
A well-integrated team of specialist physicians can be thought of as a “superdoctor.” In order for medical teams to be superdoctors, they must get to know each other’s strengths
and styles and act together seamlessly. Well- integrated teams have the combined specialized knowledge of each member and more: they have the ability to relate these different domains of knowledge and combine them in new ways. Moreover, they can act rapidly with this combined knowledge. They can be an important part of the solution to the problems of fragmentation. 

Such teams have become standard practice in cancer care, where specialists in imaging, surgery, radiation therapy, and chemotherapy often meet and work together to treat patients. The wide diversity of cancers and of individual responses to treatment make the team approach necessary for effective care. These teams generally also include non-physician practitioners. While the team approach is most widely used for cancer, some medical centers, recognizing the problem of fragmentation in care, are using the team approach for other conditions. 

To be most effective, superdoctor teams need to work together on a regular basis. If you were to throw together several sports players—even professional athletes—to play as a team without training together, they would not play as well as they would with team members who they were used to. Similarly, medical teams must “practice” together to fully leverage their collective ability...
For one thing, all of this beckons me Down in the Weeds' again (here as well). In addition, I come back to my rant of late about the enervating friction posed by "psychosocial toxicity" in the healthcare workforce.
I recently challenged another physician's blog post definition of healthcare's "toxic workplace" as perhaps too narrow (given that it was simply a petulant litany of all the ways physicians are burdened by organizational and regulatory things they dislike). His response?

"Go to hell."
Finally, I can just hear the blog trolls (usually using untraceable screen handles, but all claiming to be physicians) dismissively noting the lack of the letters "MD" in the masthead of this monograph. Yaneer Bar-Yam is a physicist. His collaborators? No clue. I don't see "MD" anywhere.

BTW, see their list of healthcare papers here.

I repeat, from my "Talking Stick" post,
It's not just about me, or you. It's about us. i.e., it's equally about interpersonal relations and mutual perceptions -- organizational dynamics. It's about "culture."

It's about "Humble Inquiry," about being "Mindwise," about the nurturing of the mutual-accountability "Just Culture" necessary for a collegial, high-engagement, high-performance interdisciplinary team-based workforce.

All of which goes necessarily to "Leadership," as leaders are the only ones with the requisite authority -- the ones who ultimately set and enforce the tone of organizational culture for better or worse. "Critical thinkers" in a psychosocially toxic organization may well simply be seen as insubordinate troublemakers.

It's about authenticity at every level within an organization, and the nurturing of a healthy culture that supports it.

...nurturing of the mutual-accountability "Just Culture" necessary for a collegial, high-engagement, high-performance interdisciplinary team-based workforce.
High morale and engagement and openness to the ongoing rigors of process improvement and effective high-cognitive burden teamwork simply requires it.
For electronic systems, auto-completion and simple check boxes should be avoided. These items are more prone to error precisely because they are quick and easy. Instead, it is important to have the prescriber provide all key information longhand and verify it. Writing something twice admittedly takes more time but the prevention of errors, as in writing checks, must be considered of primary importance.
Yeah, that'll go over really swell in the era of the put-upon provider. But, the authors are right. Consider, e.g.:
EHR Design: Default Values as a Cause of Errors

When designing software, a lot of care is given to squashing bugs. But what does one do when the design itself is the problem?  Spotlight on Electronic Health Record Errors: Errors Related to the Use of Default Values, an article published by the Pennsylvania Patient Safety Authority, sheds much needed light on this subject.  As the report notes, default values are usually considered a safety measure and not a potential source of errors.  Yet, their study found that default values introduced errors into EHR systems...

From a software design standpoint, these errors can be difficult to prevent because they rely on people to make alterations.  Using default values for medications or any type of order may seem helpful (e.g., assure some value is entered, save time by making common orders quick), but they make assumptions that, as these errors show, do not always hold.

Like many others, my encounter with this behavior happened with standard orders in hospitals.  Protocols for anticoagulants come to mind.   Systems are programmed to insist something be done, but are not necessarily smart enough to recognize a clear contraindication.  As such, the responsibility for preventing errors falls back onto busy, distracted clinicians – not a great error prevention strategy.

Attempts to prevent default values from accidentally going unchanged or assuring that user entries are accepted by the system can be maddening.  Using local validation rules (e.g., rules that apply only for that particular data entry value) makes error prevention difficult unless there is information available that provides “state” information as the process is occurring.

For example, if a user enters orders and does not change the default value, it could mean that he agrees with the default.  Of course, it could also mean that he simply forgot.  Resolving this issue requires more information about the ordering process itself. Here is one example of where workflow modeling can help in software design...
 This brought me back to my 3GL/4GL programmer days of the 80's. A "nul" value should not equate to "zero" or some other default value, but it too frequently does. Analytically, nuls must be regarded as "missing values" and static defaults must be coded with extreme care. Rigid RDBMS enforcement of stuff like "No Dupes, No Nuls" -- "relational integrity" at the data dictionary level -- is as necessary today as it was during my ancien time writing code.

BTW, Lovely comment over at THCB:
Jeff Goldsmith says:

Spoken like a spectator who’s never actually used the technology. In most EMR’s, including the market leaders, the data you actually need to “pinpoint” anything is buried six-ten clicks deep in completely unusable Windows 95 style user interfaces. If you’re lucky, you can “pinpoint” problems that happened four hours or two days ago. It’s almost impossible to find the real problems amid the bins full of templated excelsior. If you don’t believe me, ask your doctor to show you your electronic health record sometime. It’s virtually useless...
The people who’ve taken this technology furthest, like Kaiser and Geisinger, had to spend a small fortune on custom built electronic data repositories which abstract data from the patient records and organize it into useable population based files, and on custom built analytic routines and protocols to actually guide the care...

handy new timesavers???
Another zinger, same post:
platon20 says:
This article was written by an administrator who has zero experience treating patients, yet is a so-called “expert” on healthcare. Please notice the oxymoron in that.

Administrators are anxious to control doctors to “hold down costs” while at the same time paying themselves hundreds of thousands if not millions of dollars while supposedly “creating value” that doesnt exist...
Interesting concluding thoughts in the foregoing Bar-Yam et al paper:
Organizations of different types—companies, religious organizations, schools, towns, states—can set up programs that encourage people to take responsibility for their own health and lifestyle, and they can provide supportive communities toward that end. The organizations themselves can undertake new commitments to improve social health and community well-being.

Some people may want their goals and commitments to be private or to share them with friends; others may be pleased to share them publicly. The key is for familiar institutions and networks to support each person’s desire to improve his or her life and each person’s journey toward better health.

Social network follow-up interactions can be planned. Internet-based and mobile device apps with calendars, reminders, and checklists can be developed to support people in reaching their goals.

We can dramatically improve health by inspiring individual responsibility and action. When people embrace their health as a personal opportunity and are also given community support, they reveal tremendous power to make lasting improvements in their own lives and each other’s.
Upstream, baby. We will have to venture all the way "upstream."

Joe Flower has a good new post up:

Health care is fragile. It survives in a much narrower band of circumstances than most of us realize. Right now many hospitals and systems are having a second down year in a row. They’re consolidating, laying off people, working through major shifts in strategy — all because of what we must admit (if we are honest) are relatively minor economic shifts, such as small reductions in utilization and Medicare payments, a blunting of accustomed price rises, and stronger bargaining from health plans.

If minor revenue stream problems put your entire institution in jeopardy of chaotic deconstruction, it cannot be called robust.

At the same time, an increasing number of vectors outside the sealed world of health care could overwhelm and kill your institution, from climate chaos to pollution disasters to epidemics and the loss of antibiotics.

These two concatenations of threats, within and without health care, have similar and interlocking answers. The extent to which your institution is bloated, profligate of resources and highly dependent on its current streams of revenue, energy and human resources is exactly the extent to which it is a system with very little reserve capacity. In an increasingly high-variance world, your survival depends on getting green, lean, resilient and smaller...
Good stuff, Mr. Flower.


Wherein IHI moves to appropriate and brand the High Ground. I'm surprised they didn't put "TM" after the phrase "Quality Improvement" (like the ChutzpahMeister who staked out "Lean Startup®").

PDSA is PDSA, not "PDSA ®", Science is "Science," not "Science ®."

UPDATE: From the paper:
Executive Summary

In the past 25 years, improvement in health care has grown from demonstration projects into a worldwide movement. Dominant in this movement has been an improvement approach grounded in the work of Walter Shewhart, W. Edwards Deming, Joseph Juran, and Associates in Process Improvement, and shaped in practice by the staff and faculty of the Institute for Healthcare Improvement (IHI). Today, this “IHI approach” to quality improvement (referred to as “IHI-QI” throughout this paper) provides a framework for thousands of improvement practitioners around the globe. Meanwhile, many people in health care have heard about Lean and the Toyota Production System (TPS) as a powerful method for improvement and cost reduction in manufacturing, and about its notably successful application in health care by influential organizations such as Virginia Mason Medical Center and ThedaCare.

People often want to know about the relationship between IHI-QI and Lean, and how they can best utilize one or both approaches to improve their own care systems. This white paper aims to address these issues, and argues that because IHI-QI and Lean are complementary ways of approaching improvement, it is not necessary to choose one over the other as a guide to action...

IHI-QI is a vibrant discipline. It has not ossified into dogma, thanks in good measure to the diversity, energy, and idealism of its adherents, and to the “open source” approach that IHI has promoted with regard to methods and content. IHI faculty have been encouraged to candidly share their best ideas, in the belief that the field can most rapidly and effectively advance health care quality through collaboration. Together, the IHI community has grown in an atmosphere of transparency and a spirit of “all teach, all learn.”

IHI-QI is often confused with one of its core elements, the Model for Improvement (see Figure 1). The Model — three clarifying questions and the Plan-Do-Study-Act (PDSA) cycle — has formed the mainstay of IHI’s teaching and improvement methodology over the years. But despite its fame, and despite its manifest utility in almost any life situation, the Model for Improvement is not synonymous with IHI-QI.

The Model for Improvement, developed by Associates in Process Improvement, is a general purpose heuristic for learning from experience and guiding purposeful action. More simply, it is an “algorithm for achieving an aim” at any scale. As a tool for gaining practical knowledge, it represents a radical distillation of pragmatic epistemology into a habit of immediate, sequential testing of changes. One objective of this paper is to reconsider the Model for Improvement in its proper place, as a pervasive guide for action within the larger context of IHI-QI.

At present, Lean tools and methods are rapidly gaining adherents among aspiring health care improvers. As health care leaders have embraced the results-oriented discipline of industrial quality improvement, interest in more effective management systems has increased. The Toyota Production System (TPS), in particular, has received much attention. TPS is rooted in the innovations of Taiichi Ohno and colleagues in Toyota factories starting soon after the end of World War II. Adaptations of TPS are widely known by reference to one of its key principles of practice, “Lean” — the drive to devise nimble tasks, processes, and enterprises that maximize value and minimize waste in all its forms. Leading health care organizations, notably Virginia Mason Medical Center in Seattle, ThedaCare in Wisconsin, and the Pittsburgh Regional Health Initiative in Pennsylvania, have adopted TPS as their model for management and improvement, with widely recognized success...

The IHI Approach to Quality Improvement

For the purposes of this paper, we refer to IHI-QI as the approach to improvement developed by Associates in Process Improvement and promulgated by IHI, grounded in the work of W. Edwards Deming, with roots reaching deep into pragmatic philosophy, systems theory, Walter Shewhart’s statistical treatment of quality, human psychology and logic, and the scientific experimental method.

IHI-QI draws a fundamental distinction between the system to be improved and the techniques and methods used to improve it. IHI-QI seeks to formulate and codify generalizable knowledge that, when applied in other systems, can yield predictable improvements.

All improvement requires that changes be made in the system (though to be sure, not all changes are improvements). Building on the knowledge of subject matter experts, improvers target changes that are predicted to lead to improvement in a specific system. These changes are then tested and amended through iterative Plan-Do-Study-Act (PDSA) cycles to produce sustainable improvement. Such changes comprise the “content” of improvement...

In working to improve a system, IHI-QI practitioners employ an array of conceptual frameworks and methods drawn from many disciplines in order to understand and influence complex adaptive systems such as health care organizations. Selection of methods will vary greatly depending on the scope, scale, and context of the work...

Summary and Implications

Lean and the principles of TPS are in no way antithetical to the IHI approach to quality improvement, and vice versa. Lean is, in a sense, a complex and deep “application” of Profound Knowledge, a particular deployment of improvement in the realm of production systems, though it was not purposely conceived as such. IHI-QI is a general approach that guides the development and application of execution theories across a range of specified contexts to realize clearly stated goals. We can consider Lean and TPS to be an example of such an execution theory. The TPS package of interdependent change concepts was originally developed to optimize manufacturing production systems. It represents a “template” for improving such systems, with a set of predefined aims, change concepts, implementation roadmap, and tools...
Link to the full paper here. It's a good paper overall, nice historical summary of the evolution of QC/QA/QI legacy methods (long familiar to my wife and I), and a decent side-by-side tabulation of the putative "differences" between Lean and "IHI QI" (some of which, though, seem to be mere semantic quibbles in the service of turf branding).

But "Associates for Process Improvement" did not "develop" PDSA (originally called"PDCA," Plan-Do-Check-Act), they simply re-branded it with the phrase "Model For Improvement." The fact that Lean "was originally developed to optimize manufacturing production systems" is a blinding glimpse of the historically obvious (rooted in the TPS, "Toyota Production System"), and is irrelevant to its successful adaptation and application within various service industries, including the most complex of all, healthcare.

Old wine, new bottle?
(scroll down in the link)
Moreover, on the repeated "Lean is about reducing cost" thing, Lean Sensei Mark Graban writes:
Lean is Not About Cutting Costs...

Two pet peeves of mine are hearing people say things like “Lean is all about reducing waste” and or “Lean is all about cost cutting” (and thankfully others are also trying to dispel that myth). Another pet peeve is people drawing conclusions off of two data points, but we’ll come back to that later in this post.

Lean is not “all about” waste — we also focus on providing the right “value” to the patient or customer (doing the right thing the right way at the right time and the right place). Reducing waste is a big part of Lean, but it’s not the only thing.

Of course, we know that reducing waste is not exactly the same as “cutting costs.” Reducing wasteful activity in a process or value stream will often lead to lower cost, but it also leads to better flow and better quality, among other things...
Again, there's a ton of overlap/wiggle room in all of these characterizations. See also Mark's post
Lean is a “Generic” Term for TPS (and The Toyota Way), Says Dan Jones

More to come...

The ultimate population health "Upstream" issue?

Click the Abstract images to enlarge for reading. The JAMA Network Reader doesn't permit screen-scraping of text. Below, from another of my blogs, Some photos of mine.

See also my post "The Next Anasazi ruin?

From the NY Daily News:
Effects of climate change could worsen public health: study
Extreme heat can exacerbate heart problems, respiratory issues and other health conditions. New York, get ready for three times as many hot days by 2050.

Climate change isn't just worrisome for the Earth.

It could also be a problem for your health, according to a new 20-year study in the Journal of the American Medical Association.

Researchers from the Global Health Institute at the University of Wisconsin-Madison looked at 56 medical journal articles about climate change's impact on health, plus air temperature information from the National Oceanic and Atmospheric Administration’s National Climatic Data Center.

They found that numerous cities in the U.S. will have many more days of high-heat temperatures by 2050. Urban areas like New York City can expect those days to triple.

And the health implications of those extreme temperatures are scary: worsening of respiratory disorders, heart conditions, infectious diseases, reduced food availability and mental health disorders such as depression and PTSD that result after natural disasters.

Reducing climate change could thus possibly reduce our nation's health problems. In a related editorial, JAMA editor in chief Dr. Howard Bauchner and executive editor Dr. Phil B. Fontanarosa wrote that it is just as threatening to our public health as "lack of sanitation, clean water, and pollution (were) in the 20th century."

"Understanding and characterizing this threat and educating the medical community, public, and policy makers are crucial if the health of the world's population is to continue to improve during the latter half of the 21st century," they said.
Yeah, but at least the North Slope Point Barrow Pino Noir should be excellent. /s

apropos, see my 2008 post "0.0143%"

From "The Upstream Doctors"
More than 2,400 years ago, Hippocrates, the father of Western medicine, opened his classic On Airs, Waters, and Places with this advice:
Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces for they are not at all alike, but differ much from themselves in regard to their changes. Then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality. We must also consider the qualities of the waters, for as they differ from one another in taste and weight, so also do they differ much in their qualities. In the same manner, when one comes into a city to which he is a stranger, he ought to consider its situation, how it lies as to the winds and the rising of the sun; for its influence is not the same whether it lies to the north or the south, to the rising or to the setting sun. These things one ought to consider most attentively, and concerning the waters which the inhabitants use, whether they be marshy and soft, or hard, and running from elevated and rocky situations, and then if saltish and unfit for cooking; and the ground, whether it be naked and deficient in water, or wooded and well watered, and whether it lies in a hollow, confined situation, or is elevated and cold; and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labor, and not given to excess in eating and drinking.
 Hippocrates and a long line of standard-bearers who have followed him have called for an approach in medicine that is capable of appreciating and addressing the social context of health.* I share the hope that all patients and professionals within the health care system better understand this.

Manchanda, Rishi (2013-06-06). The Upstream Doctors: Medical Innovators Track Sickness to Its Source (Kindle Single) (TED Books) (Kindle Locations 878-892). TED Conferences. Kindle Edition. 

More to come...

Thursday, September 25, 2014

A Health 2.0 2014 Conference reflection

So, beyond the always-dazzling parade of cutting-edge, beautifully rendered tech stuff (mostly software, but, yeah, some hardware gizmos, mostly mated with smartphones), there was an enormous, significantly increased amount of buzz at @Health2con regarding our imperative to all move toward broadly defined "wellness" -- in contrast to the prevailing, problematic paradigm of our evolved, bankrupting "Sickcare System." Recall, from my citation in a prior post, the estimation that only ~10% of health is attributable to clinical interventions?

Yeah, we're all gonna productively live to 150 in the wake of our having effectively addressed all of the Upstream issues, via full mobile personal digital quantification and recursively aggregated Big Data "Predictalyics," eh?

Went to my mailbox today. My new Atlantic Magazine had arrived. [Bleep]. Like I don't have enough to do today. Grrrrr... I gotta get up at 4 to have my daughter to BART before 5 a.m. for her trip back east, and laundry and housecleaning loom nigh. An old friend of mine (and former bandmate) is gigging at Yoshi's in Oakland tomorrow night; I gotta go shoot the show. The cats have to go to the vet on Saturday for overdue exams and shots, and then Cheryl returns on Sunday from Alabama where she's been taking care of her ailing Mom. Fresh roses, clean sheets and pillowcases...

Reading is my crack cocaine. I am an addict. Had to stop and read.

For millennia, if not for eons—anthropology continuously pushes backward the time of human origin—life expectancy was short. The few people who grew old were assumed, because of their years, to have won the favor of the gods. The typical person was fortunate to reach 40.

Beginning in the 19th century, that slowly changed. Since 1840, life expectancy at birth has risen about three months with each passing year. In 1840, life expectancy at birth in Sweden, a much-studied nation owing to its record-keeping, was 45 years for women; today it’s 83 years. The United States displays roughly the same trend. When the 20th century began, life expectancy at birth in America was 47 years; now newborns are expected to live 79 years. If about three months continue to be added with each passing year, by the middle of this century, American life expectancy at birth will be 88 years. By the end of the century, it will be 100 years.

Viewed globally, the lengthening of life spans seems independent of any single, specific event. It didn’t accelerate much as antibiotics and vaccines became common. Nor did it retreat much during wars or disease outbreaks. A graph of global life expectancy over time looks like an escalator rising smoothly. The trend holds, in most years, in individual nations rich and poor; the whole world is riding the escalator.

Projections of ever-longer life spans assume no incredible medical discoveries—rather, that the escalator ride simply continues. If anti-aging drugs or genetic therapies are found, the climb could accelerate. Centenarians may become the norm, rather than rarities who generate a headline in the local newspaper...
Full article link.
We all come and go unknown
Each so deep and superficial
Between the forceps and the stone
Well I looked at the granite markers
Those tribute to finality to eternity
And then I looked at myself here
Chicken scratching for my immortality
In the church they light the candles
And the wax rolls down like tears
There's the hope and the hopelessness
I've witnessed thirty years
We're only particles of change I know I know
Orbiting around the sun ...

-Joni Mitchell, Hejira


That’s how long I want to live: 75 years.

This preference drives my daughters crazy. It drives my brothers crazy. My loving friends think I am crazy. They think that I can’t mean what I say; that I haven’t thought clearly about this, because there is so much in the world to see and do. To convince me of my errors, they enumerate the myriad people I know who are over 75 and doing quite well. They are certain that as I get closer to 75, I will push the desired age back to 80, then 85, maybe even 90.

I am sure of my position. Doubtless, death is a loss. It deprives us of experiences and milestones, of time spent with our spouse and children. In short, it deprives us of all the things we value.

But here is a simple truth that many of us seem to resist: living too long is also a loss. It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived. It robs us of our creativity and ability to contribute to work, society, the world. It transforms how people experience us, relate to us, and, most important, remember us. We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic...
Full article link.

My favorite "afterlife" speculation is here.

COLLEGE PARK, Maryland—Kira Adam was tired of waiting. When she first noticed the cavity about six months ago, she tried to book a dentist’s appointment, but she had trouble finding a practice that would take her Medicaid insurance.

“Every time I tried to schedule it, it was a two to three month wait” for an appointment, she told me.

The cavity got worse. When she finally did get seen, the dentist told her she would need a root canal. It would cost $1,000, and her insurance would pay nothing.

“He told me to come back when I had the money,” she said. As a baker at Panera Bread, she knew it would be a while before she did. She applied for and received a loan through CareCredit, a medical financing company, but it was a few hundred dollars short. So she waited some more—and tried to ignore the pain that was now shooting through her jaw...
Full article link.

The latter one reminds me of a New Yorker piece, one I cited years ago on one of my other blogs.
The Moral-Hazard Myth
The bad idea behind our failed health-care system.


Tooth decay begins, typically, when debris becomes trapped between the teeth and along the ridges and in the grooves of the molars. The food rots. It becomes colonized with bacteria. The bacteria feeds off sugars in the mouth and forms an acid that begins to eat away at the enamel of the teeth. Slowly, the bacteria works its way through to the dentin, the inner structure, and from there the cavity begins to blossom three-dimensionally, spreading inward and sideways. When the decay reaches the pulp tissue, the blood vessels, and the nerves that serve the tooth, the pain starts—an insistent throbbing. The tooth turns brown. It begins to lose its hard structure, to the point where a dentist can reach into a cavity with a hand instrument and scoop out the decay. At the base of the tooth, the bacteria mineralizes into tartar, which begins to irritate the gums. They become puffy and bright red and start to recede, leaving more and more of the tooth’s root exposed. When the infection works its way down to the bone, the structure holding the tooth in begins to collapse altogether.

Several years ago, two Harvard researchers, Susan Starr Sered and Rushika Fernandopulle, set out to interview people without health-care coverage for a book they were writing, “Uninsured in America.” They talked to as many kinds of people as they could find, collecting stories of untreated depression and struggling single mothers and chronically injured laborers—and the most common complaint they heard was about teeth. Gina, a hairdresser in Idaho, whose husband worked as a freight manager at a chain store, had “a peculiar mannerism of keeping her mouth closed even when speaking.” It turned out that she hadn’t been able to afford dental care for three years, and one of her front teeth was rotting. Daniel, a construction worker, pulled out his bad teeth with pliers. Then, there was Loretta, who worked nights at a university research center in Mississippi, and was missing most of her teeth. “They’ll break off after a while, and then you just grab a hold of them, and they work their way out,” she explained to Sered and Fernandopulle. “It hurts so bad, because the tooth aches. Then it’s a relief just to get it out of there. The hole closes up itself anyway. So it’s so much better.”

People without health insurance have bad teeth because, if you’re paying for everything out of your own pocket, going to the dentist for a checkup seems like a luxury. It isn’t, of course. The loss of teeth makes eating fresh fruits and vegetables difficult, and a diet heavy in soft, processed foods exacerbates more serious health problems, like diabetes. The pain of tooth decay leads many people to use alcohol as a salve. And those struggling to get ahead in the job market quickly find that the unsightliness of bad teeth, and the self-consciousness that results, can become a major barrier. If your teeth are bad, you’re not going to get a job as a receptionist, say, or a cashier. You’re going to be put in the back somewhere, far from the public eye. What Loretta, Gina, and Daniel understand, the two authors tell us, is that bad teeth have come to be seen as a marker of “poor parenting, low educational achievement and slow or faulty intellectual development.” They are an outward marker of caste. “Almost every time we asked interviewees what their first priority would be if the president established universal health coverage tomorrow,” Sered and Fernandopulle write, “the immediate answer was ‘my teeth.’ ”...
So much to dwell upon. Glad I'm now "retired."

The Atlantic is wrong about aging: Why our anti-elderly bias needs to change
In an Atlantic cover story, Dr. Ezekiel Emanuel says life after 75 isn't worth living. Here's why he's very wrong


Dr. Emanuel, now 57 years old, is smart, mature, productive and provocative in his ideas about avoiding aging. He is the age of my son, who was a colleague of his at the National Institutes of Health. At 86, I look at them both as “young” and still growing up. Unfortunately, Emanuel’s recent essay in The Atlantic — titled “Why I hope to die at 75″ — has contributed tremendously to the negative views of aging that plague our society today. I am as passionate about changing these attitudes as Dr. Emanuel is about dying less than two decades from now. So is my 51-year-old colleague and co-author, psychologist Mindy Greenstein. Why?

Dr. Emanuel’s image of life after 75 is bleak indeed: a time of deprivation and loss of creativity, a time when we are sluggish and no longer able to contribute to the world around us. He especially fears being remembered as “feeble, ineffectual, even pathetic.”

I am an elder who has treated older patients with cancer for over 35 years at Memorial Sloan Kettering Cancer Center, helping them cope with the challenges of being ill. Dr. Greenstein is a clinical psychologist and consultant to my geriatric psychiatry group. Clinical experience and much social science research refute many of Dr. Emanuel’s assumptions about life after 75. Large population studies by economists and psychologists asked adults of all ages, and from different countries, to rate their sense of well-being on a scale of 1 to 10. When they looked at the data by age, they found it had a fascinating shape: a “U.”

Self-reported well-being starts relatively high for people in their early twenties, after which time it starts to steadily decrease, particularly for the “sandwich generation.” Well-being plummets to its lowest level for people in their early fifties. After this trough, well-being starts to increase again, and keeps increasing over the years, until, by age 85, it’s even higher than it is for those in their twenties...

One more, apropos of this whole (naively cherubic, IMHO) "population health" mantra, also effusively on display at @Health2con.
Could Population Health Be Considered Discrimination?

...When the government talks about population health, they mean the entire population. When you start paying organizations based on the health of their patient population, it changes the dynamic of who you want to include in your patient population. Another possible opportunity for discrimination...
AKA "Business Intelligence," no? This issue came up briefly during one of the late day three sessions, wherein one of the panelists posed the question regarding the extent to which health care systems should be required to convey to public authorities de-ID'd patient data useful for population health analytics. Contentious, to be sure.


On "Empathy," (from an "Unmentionables" panel slide). "Broken People." Lyrics ensue at 0:30. Listen carefully. Spiritual, empathetic, compassionate. Beautifully stated. Sure to be scoffed at by the Ayn Randianistas.

When we open up our eyes,
Are we prepared to see the world with no disguise?
Will we listen to the call
Coming from a distant cry,
From a truth that we've denied,

Coming from all the broken people,
Do we even dare
Look at all the hurting people,
And show them that we care?...
It's called Health CARE, we must always remember.

Ole Borud. Magnificent young Norwegian R&B cat. Sat in with my Vegas pals. Recorded a live DVD that night. I did the cover art and photography. A great show.

More on "empathy":
Many African traditions speak of a concept known as ubuntu: “a person is a person through other persons.” Your humanity comes from the way you treat others, the idea goes, not the way you behave in isolation. Humanity comes from treating others as human beings, not in the biological sense of having a fully human body but in the psychological sense of having a fully human mind.
From the book Mindwise, cited in one of my recent posts (scroll down). The way you treat others is to a material degree a function of the extent (and accuracy) of your empathic view of them. How well can you put yourself "in another's shoes"? How much do you even care to try to do so?


That presentation blew my mind. Restoring long-term memory via digital hippocampus implants? Recall my goofy Photoshop from one of my prior posts?

Military's Tiny Implant Could Give People Self-Healing Powers
The Huffington Post, By Dominique Mosbergen, 09/26/14

If a tiny device could be implanted in your body to give you self-healing powers, would you want one?

That question is on many minds now that the Defense Department's Advanced Research Projects Agency (DARPA) has announced that just such a device is in the works: an electronic implant, injected via a needle, that would monitor the health of internal organs and help the body heal itself when illness or injury strikes.

The implant -- being developed as part of the agency's ElectRx (pronounced “electrics”) program -- would “fundamentally change the manner in which doctors diagnose, monitor and treat injury and illness,” DARPA program manager Doug Weber said in a written statement.

“Instead of relying only on medication -- we envision a closed-loop system that would work in concept like a tiny, intelligent pacemaker," Weber continued. "It would continually assess conditions and provide stimulus patterns tailored to help maintain healthy organ function, helping patients get healthy and stay healthy using their body’s own systems."

There's no word yet on when such a device might become available, but a spokesman for the agency said clinical trials might begin within five years.

DARPA says the ElectRx implant would work via a process akin to neuromodulation. That's the body's built-in biological feedback system in which the peripheral nervous system -- the nerves linking the brain and spinal cord to the rest of the body -- monitors and regulates the body’s response to injury and infection...

'eh? Lurching toward "Singularity" piecemeal?

Below: Recently read this (mostly firewalled) article in my Harper's:

Neuroscientists who work on the human brain seldom mention free will. Most consider it a subject better left, at least for the time being, to philosophers. Meanwhile, their sights are set on discovering the physical basis of consciousness, of which free will is a part. No scientific quest is more important to humanity. Everyone — scientists, philosophers, and religious believers alike — can agree with the neurobiologist Gerald Edelman that “[c]onsciousness is the guarantor of all we hold human and precious. Its permanent loss is considered equivalent to death, even if the body persists in its vital signs.”

The physical basis of consciousness won’t be an easy phenomenon to grasp. The human brain is the most complex system, either organic or inorganic, known in the universe. Each of the billions of nerve cells (neurons) composing its functional part forms synapses and communicates with an average of ten thousand others; each launches messages along its own axon pathway using an individual digital code of membrane-firing patterns. The brain is organized into regions, nuclei, and staging centers that divide functions among them. These regions respond in different ways to hormones and sensory stimuli originating from outside the brain, while sensory and motor neurons all over the body communicate so intimately with the brain as to be virtually a part of it...
Philosophers have labored for more than two thousand years to explain consciousness. Innocent of biology, however, they have for the most part gotten nowhere. I don’t believe it too harsh to say that the history of philosophy when boiled down consists mainly of failed models of the brain. A few contemporary neurophilosophers, such as Patricia Churchland and Daniel Dennett, have made splendid efforts to interpret neuroscience research as it has become available. They have helped to demonstrate, for example, the ancillary nature of morality and rational thought. Others, especially those of poststructuralist bent, are more retrograde. Theydoubt that the “reductionist” or “objectivist” program of brain researchers will ever succeed in explaining the core of consciousness. Even if it has a material basis, subjectivity in this view is beyond the reach of science. To make their argument, the mysterians (as they are sometimes called) point to the qualia—the subtle, almost inexpressible feelings we experience about sensory input. For example, “red” we know from physics, but what are the deeper sensations of “redness”? And if we can’t answer that, then what can scientists ever hope to tell us on a larger scale about free will or about the soul?

Neuroscientists, to their credit, have no illusions about the difficulty of the task. They agree with Darwin that the mind is a citadel that cannot be taken by frontal assault. They have set out instead to break through to its inner recesses with multiple probes along the ramparts, opening breaches here and there; by technical ingenuity and force they hope to enter and explore wherever they find space to maneuver. 

You have to have faith to be a neuroscientist. We don’t know where consciousness and free will may be hidden—assuming they even exist as integral processes and entities. Meanwhile, neuroscience has grown rich, primarily because of its relevance to medicine. Its research projects are growing on budgets of hundreds of millions to billions each year (in the science trade it’s called Big Science). The same surge has occurred in cancer research in designing the space shuttle, and in experimental particle physics.

Perhaps, then, a direct assault is possible after all. The Brain Activity Map (BAM) Project, led by the National Institutes of Health, has the goal of generating a map of the activity of every neuron in real time. The program, if successfully funded, will parallel in magnitude the Human Genome Project. Much of the technology will have to be developed on the job.

The basic goal of activity mapping is to connect all of the processes of thought—rational and emotional; conscious, preconscious, and unconscious; held still and moving through time—to a physical base. It won’t come easy. Bite into a lemon, fall into bed, recall a departed friend, watch the sun sink beyond the western sea. Each episode comprises mass neuronal activity so elaborate we cannot even conceive of it, much less write it down as a repertory of firing cells...

Edward O. Wilson is the author of more than thirty books, including two Pulitzer Prize winners. His new book, The Meaning of Human Existence, will be published in October by Liveright. 

I seriously look forward to that book.

Note on the word "philosopher." It derives from the ancient "philo" (love) "sophia" (knowledge). "Lover of knowledge," not the inscrutable, pedantic, hyperpseudoerudite ivory tower MEGO babbler we frequently conjure up upon encountering the term.



THCB comment today (Friday)


From the always astute Neil Versel:
Health 2.0 grows up to fight silos
Gone are the 'flighty, flaky' ideas of 2007, in is focus on connecting disparate systems.
SANTA CLARA, CA | September 26, 2014

Now in its eighth year, the annual Health 2.0 Fall Conference has evolved from a showcase for not-ready-for-prime-time apps that wouldn't exist a year later to a self-congratulatory Silicon Valley pep rally to a more mature event that seems to be addressing real-world healthcare problems.

Health 2.0 Conference co-founder and CEO Indu Subaiya, MD, opened the conference by saying that in her mind, there are four stages of health 2.0. The original definition of health 2.0, now considered stage 1, is user-generated care. From there, users connect to providers to send their data; form partnerships to reform care delivery; and, ultimately, data drives healthcare decisions and discovery, Subaiya said.

Like the rest of the healthcare industry, the health 2.0 movement is hard at work on the second stage, namely connecting disparate systems so data flows where patients and clinicians want it to. As with everyone else, it appears to be a formidable task, plus, so many new apps risk creating new data silos...
Good assessment of @Health2con, IMO. My "Interoperababble" concerns persist, though.


If It Looks Like A Bubble, And Quacks Like A Bubble ...
Todd Hixon, for Forbes
Then it’s best not to build your house on it. Silicon Valley sure looks like a bubble to me, and many others think so too. While these are heady times, it’s actually very difficult to start new investments. Some back-to-basics thinking is the best way to mitigate the risk.

I spent several days at a conference in Silicon Valley recently and then visited venture capital friends on Sand Hill Road. The venture capital market there is dramatically different from the rest of the U.S., even New York, which is having a good run...

At the Health 2.0 conference, which I attended, there was much moxie on display, including a digital health wearables fashion show complete with a runway and a custom music mix. I heard comments, however, that digital health investors are starting to see a lot of me-too offerings: if you closed your eyes and walked 100 feet, you’d bump into three companies selling systems to reduce hospital re-admissions.

Many VCs are wondering, how do you invest into this market with a decent chance of success? If you are chasing the companies that have visibly achieved “escape velocity” in their markets, you are competing with the great names and greater check books. Only a handful can succeed in that game. And then you pay a price based on perfection and bet on continuation of aggressive growth financings and a hot IPO market.

If you play at the seed level, you compete with the host of angels, accept weak terms, and invest in companies in which entrepreneurs may be on their own because seed investors often can’t help, don’t spend the time, or lack governance levers when the going gets tough. And occasionally the big funds reach down and take over an early financing with a big check at a high price, squeezing other investors out. One VC blogger calls this a “piggy round”.

Burn rates are running $500k to $1 million per month and up, in many cases (more). This presumes the ability to keep financing on favorable terms. If not, the blood quickly gets ankle-deep.

This market dynamic looks delicate to me. While the Internet continues to grow and entrepreneurs keep finding new opportunities, the sources of money fueling much of the boom are fickle. The scope of the hot segments market is narrow: largely confined to Silicon Valley and a half-dozen sectors. If the end comes fast, many companies will quickly be in mortal jeopardy: burn rates, valuations, and capital structures will be crushed...
Ouch. "[I]f you closed your eyes and walked 100 feet, you’d bump into three companies selling systems to reduce hospital re-admissions." LOL. My first assignment in 1993 with the Nevada Peer Review (QIO) involved running Stata code against HCFA claims data (pdf), mining for, among other things, 5- and 30-day acute care readmit causally inferential associations.

More to come...