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Tuesday, February 17, 2015

On ONC's "non-regulatory, market-driven" Health IT fetish, and other related business

My new Harper's arrive in the snailmail the other day. Couple of interesting pieces therein, relevant, IMO, to the high-minded muddleheadedness I see coming out of places like ONC in the wake of the JASON Report.

A couple of JASON gems:
  • Establish an industry-based ecosystem. A Coordinated Architecture based on market-based arrangements should be defined to create an ecosystem to support API-based interoperability.
  • Institute the government as market motivator. ONC should assertively monitor the progress of exchange and implement non-regulatory steps to catalyze the adoption of Public APIs.
"Implement non-regulatory steps"? Seriously? See also my February 1st post Yet another ONC Interoperability "Roadmap" e.g.,
It is now 2015. Lordy. Do I really need to elaborate here? This is a recipe for the ever-so-collegial continuation of stasis, all elaborated reported on episodically in lengthy, aesthetically pleasing pdf documents verbosely re-plowing the same ground. And, the putative upshot will be that (re Figure 1) we will "simplify" and "focus on value" to "empower individuals" through "scalable universal access," all while "maintaining modularity," recognizing that "one size does not fit all," in deference to "considering the current environment" and "building on existing infrastructure" so as to "leverage the market."
Yeah, I know, markets uber alles, with disdain for "regulation" in increasingly full-throated neo-Randian, pitchfork-wielding, populist tool you're-not-the-not-the-boss-of-ME political roar.

Never mind pesky little annoying realities such as "First Mover Disadvantage," "Opacity = Margin," and "Gresham's Dynamic." Never mind the Moral Hazard race-to-the-bottom FIRE Sector Crash of 2008. We're marching euphorically arm-in-arm toward the inevitable hyperefficient, innovative, beneficent, free-market UberTopia. An App in Every Pot.

From my March 2015 (subscriber-paywalled) issue of Harper's:

In Regulation Nation
By David Graeber,

 from The Utopia of Rules, published last month by Melville House. Graeber is the author of Debt: The First 5,000 Years...
When we do discuss bureaucracy, we still use terms established in the Sixties and Seventies. The social movements of the Sixties were, on the whole, left-wing in inspiration, but they were also rebellions against the bureaucratic mind-set, the gray functionalism of both state-capitalist and state-socialist regimes, the soul-destroying conformity of the postwar welfare states. In the face of social control, Sixties rebels stood for individual expression and spontaneous conviviality.
With the collapse of the old welfare states, this kind of rebellion has come to seem decidedly quaint. As the right has adopted the language of anti-bureaucratic individualism, insisting on “market solutions” to every social problem, the mainstream left has limited itself to salvaging remnants of the old welfare state. It has acquiesced to — and often spearheaded — traditionally right-wing attempts to make government efforts more “efficient,” whether through the privatization of services or the incorporation of “market principles,” “market incentives,” and marketbased “accountability processes.”...
At least the right has a critique of bureaucracy. Its origins may be found in the nineteenth century, when liberal thinkers argued that Western civilization was undergoing a gradual, uneven, but inevitable transformation from the rule of warrior-elites to a society of liberty, equality, and enlightened commercial self-interest. In the wake of the French Revolution, absolutist states were giving way to markets, religious faith to scientific understanding, and fixed orders and noble ranks to free contracts between individuals.
The right-wing argument goes one step further. Ludwig von Mises, the exiled Austrian aristocrat and economic theorist who was its greatest twentieth-century exponent, argued in his 1944 book, Bureaucracy, that systems of government administration could never organize information with anything like the efficiency of impersonal market-pricing mechanisms, and that the administrators of social programs would end up destroying the political basis of democracy by forming powerful blocs against elected officials. Even well-meaning bureaucrats would do more harm than good.
The idea that the market is somehow opposed to and independent of government has been used at least since the nineteenth century to justify laissez-faire economic policies, but such policies never actually have the effect of lessening the role of government. In late-nineteenth-century England, for instance, an increasingly liberal society did not lead to a reduction of state bureaucracy but the opposite: an endlessly mushrooming array of legal clerks, registrars, inspectors, notaries, and police officials — the very people who made possible the liberal dream of a world of free contract between autonomous individuals. It turned out that maintaining a free-market economy required considerably more paperwork than a Louis XIV–style absolutist monarchy. The same effect could be seen in America during Ronald Reagan’s presidency, or in Russia after the fall of the Soviet Union, where, from 1994 to 2002, the number of civil servants jumped by some quarter million.
Indeed, this paradox can be observed so regularly that I think we are justified in treating it as a general sociological principle. Let’s call it the Iron Law of Liberalism: Any market reform or government initiative intended to reduce red tape and promote market forces will ultimately increase the number of regulations and bureaucrats, as well as the amount of paperwork, that the government employs. Emile Durkheim was already observing this tendency at the turn of the twentieth century, and fifty years later even right-wing critics like F. A. Hayek were willing to admit that markets don’t really regulate themselves: they require an army of administrators to keep them going.
Still, conservative populists recognized that making a target of bureaucrats was almost always effective, whatever the reality... Americans now generally believe government to comprise two sorts of people: “politicians,” who are blustering crooks and liars but can at least occasionally be voted out of office, and “bureaucrats,” who are condescending elitists and almost impossible to uproot. The right-wing argument tends to assume a kind of tacit alliance between a parasitic poor (in America usually pictured in overtly racist terms) and equally parasitic self-righteous officials who subsidize the poor using other people’s money. Even the mainstream left now offers little more than a watered- down version of this language. Bill Clinton, for instance, spent so much of his career bashing civil servants that after the Oklahoma City bombing in 1995, he felt he had to remind Americans that public servants were human beings, too.
In America — and increasingly in the rest of the world — the only alternative to “bureaucracy” is now “the market.” Sometimes this is taken to mean that the government should be run more like a business, other times that we should get bureaucrats out of the way and let the magic of the marketplace provide its own solutions. “Democracy” has become a synonym for “the market,” just as “bureaucracy” has become one for “government interference.”...
So what are people referring to when they talk about deregulation? In ordinary usage, the word seems to mean “changing the regulatory structure in a way that I like.” In the case of banking, deregulation has usually meant moving away from a situation of managed competition between midsize firms to one in which a handful of financial conglomerates are allowed to completely dominate the market. In the case of airlines and telecommunication firms in the Seventies and Eighties, deregulation meant the opposite: changing the system of regulation from one that encouraged a few large firms to one that fostered carefully supervised competition between midsize firms. In neither of these cases was bureaucracy reduced...
What began to happen in the Seventies, which paved the way for what we see today, was a strategic turn, as the upper echelons of U.S. corporate bureaucracy moved away from workers and toward shareholders. There was a double movement: corporate management became more financialized and the financial sector became more corporatized, with investment banks and hedge funds largely replacing individual investors. As a result, the investor class and the executive class became almost indistinguishable. By the Nineties, lifetime employment, even for white-collar workers, had become a thing of the past...
Bureaucratic techniques developed in financial and corporate circles (performance reviews, focus groups, time-allocation surveys, and so on) spread throughout the rest of society, to education, science, and government. One can trace the process by following its language. There is a peculiar idiom that first emerged in corporate circles, full of bright, empty terms like “vision,” “quality,” “stakeholder,” “leadership,” “excellence,” “innovation,” “strategic goals,” and “best practices.” Much of it originated from “self-actualization” movements like Mind Dynamics, Lifespring, and est, which were extremely popular in corporate boardrooms in the Seventies. But it quickly became a language unto itself, engulfing any meeting where any number of people gather to discuss the allocation of any kind of resources...
"Bright, empty terms" indeed. Recall my January 18th post "Let a thousand banalities bloom."

David Graeber is an utter delight to read. I had the good fortune to buy and read his excellent book "Debt: the first 5,000 years" before I knew who he is. A witty, erudite book comprising the best of the word "scholarship" (his politics aside, he's a social anthropologist). If you want a free Cliff's Notes version, see his piece "To Have is to Owe."

His new book "The Utopia of Rules" will not be available until February 24th. I will get it and read it as soon as it is released.

Interesting snip from the Amazon preview (I Dragon'ed it in):
Here I think it is possible to add a kind of corollary to the Iron Law of Liberalism. History reveals the political policies that favor "the market" have always meant even more people in offices to administer things, but it also reveals that they also mean an increase of the range in density of social relations that are ultimately regulated by the threat of violence. This obviously flies in the face of everything we've been taught to believe about the market, but if you observe what actually happens, it's clearly true in a sense, even calling this a "corollary" is deceptive, because were really just talking about two different ways of talking about the same thing. The bureaucratization of daily life means the imposition of impersonal rules and regulations; in personal rules and regulations, in turn, can only operate if they are backed up by the threat of force.
The "threat of force" need not be one of physical violence. And it need not be that of "government." Private market corporate coercion may be all the more pernicious in light of its lack of practical legal accountability.

Which leads me into the 2nd Harper's article,
The Spy Who Fired Me
By Esther Kaplan

Last March, Jim Cramer, the host of CNBC’s Mad Money, devoted part of his show to a company called Cornerstone OnDemand. Cornerstone, Cramer shouted at the camera, is “a cloud-based-software-as-a-service play” in the “talent-management” field. Companies that use its platform can quickly assess an employee’s performance by analyzing his or her online interactions, including emails, instant messages, and Web use. “We’ve been managing people exactly the same way for the last hundred and fifty years,” Cornerstone’s CEO, Adam Miller, told Cramer. With the rise of the global workforce, the remote workforce, the smartphone and the tablet, it’s time to “manage people differently.” Clients include Virgin Media, Barclays, and Starwood Hotels.

Cornerstone, as Miller likes to tell investors, is positioning itself to be “on the vanguard of big data in the cloud” and a leader in the “gamification of performance management.” To be assessed by Cornerstone is to have your collaborative partnerships scored as assets and your brainstorms rewarded with electronic badges (genius idea!). It is to have scads of information swept up about what you do each day, whom you communicate with, and what you communicate about. Cornerstone converts that data into metrics to be factored in to your performance reviews and decisions about how much you’ll be paid.

Miller’s company is part of an $11 billion industry that also includes workforce-management systems such as Kronos and “enterprise social” platforms such as Microsoft’s Yammer, Salesforce’s Chatter, and, soon, Facebook at Work. Every aspect of an office worker’s life can now be measured, and an increasing number of corporations and institutions — from cosmetics companies to car-rental agencies — are using that information to make hiring and firing decisions. Cramer, for one, is bullish on the idea: investing in companies like Cornerstone, he said, “can make you boatloads of money literally year after year!”

A survey from the American Management Association found that 66 percent of employers monitor the Internet use of their employees, 45 percent track employee keystrokes, and 43 percent monitor employee email. Only two states, Delaware and Connecticut, require companies to inform their employees that such monitoring is taking place. According to Marc Smith, a sociologist with the Social Media Research Foundation, “Anything you do with a piece of hardware that’s provided to you by the employer, every keystroke, is the property of the employer. Personal calls, private photos — if you put it on the company laptop, your company owns it. They may analyze any electronic record at any time for any purpose. It’s not your data.”

With the advent of wireless connectivity, along with a steep drop in the price of computer processors, electronic sensors, GPS devices, and radio-frequency identification tags, monitoring has become commonplace. Many retail workers now clock in with a thumb scan. Nurses wear badges that track how often they wash their hands. Warehouse workers carry devices that assign them their next task and give them a time by which they must complete it. Some may soon be outfitted with augmented-reality devices to more efficiently locate products.

In industry after industry, this data collection is part of an expensive, high-tech effort to squeeze every last drop of productivity from corporate workforces, an effort that pushes employees to their mental, emotional, and physical limits; claims control over their working and nonworking hours; and compensates them as little as possible, even at the risk of violating labor laws. In some cases, these new systems produce impressive results for the bottom line: after Unified Grocers, a large wholesaler, implemented an electronic tasking system for its warehouse workers, the firm was able to cut payroll expenses by 25 percent while increasing sales by 36 percent. A 2013 study of five chain restaurants found that electronic monitoring decreased employee theft and increased hourly sales. In other cases, however, the return on investment isn’t so clear. As one Cornerstone report says of corporate social-networking tools, “There is no generally accepted model for their implementation or standard set of metrics for measuring R.O.I.” Yet this has hardly slowed adoption...

first got interested in the data-driven workforce not long after I moved from a dilapidated apartment in Brooklyn that had a live-in super to a slightly more solid walk-up that does not. I began to notice something frustrating about my UPS deliveries. They never arrived. When I wasn’t home, I’d leave a note asking for packages to be left at the laundromat on the corner. I’d get an attempted-delivery note instead. The same thing sometimes happened even when I was home — I’d find an attempted-delivery note, but no one had rung my doorbell. Packages were routinely returned to sender. Then I learned about UPS’s use of something called telematics.

Telematics is a neologism coined from two other neologisms — telecommunications and informatics — to describe technologies that wirelessly transmit data from remote sensors and GPS devices to computers for analysis. The telematics system that now governs the working life of a driver for UPS includes handheld DIADs, or delivery-information acquisition devices, as well as more than 200 sensors on each delivery truck that track everything from backup speeds to stop times to seat-belt use. When a driver stops and scans a package for delivery, the system records the time and location; it records these details again when a customer signs for the package. Much of this information flows to a supervisor in real time. The Teamsters, the union that represents UPS employees, won contract language that says drivers can’t be fired based solely on the numbers in their telematics reports, but supervisors have found workarounds, and telematics-related firings have become routine.

One warm day last fall I met with a man I’ll call Jeff Rose, who for the past fifteen years has driven a UPS delivery route in a working-class neighborhood in one of New York City’s outer boroughs. He was taking his two o’clock lunch break at a diner on the corner of a modest commercial strip and a leafy residential street. Rose, who asked that I not use his real name, said that telematics was introduced as a safety measure when it was rolled out in New York six or seven years ago. Lists were posted at distribution centers to shame the biggest seat-belt scofflaws. But safety is not the reason given for telematics on UPS investor calls. On those, executives speak instead about the potential for telematics to save the firm $100 million in operating efficiencies, including reductions in fuel, maintenance, and labor...
I am reminded of a book I cited last April and again in June.

Efficient, Lean "market-driven" digital "utopia" or a digital Panopticon dystopia?

Esther Kaplan concludes:
The current mythology of big data,” according to Kate Crawford, who holds research positions at MIT, NYU, and Microsoft, “is that with more data comes greater accuracy and truth.” Big data in the workplace holds out the promise of true equality of opportunity, in which Moneyball-style analytics unearth hidden talent. Yet Kronos’s metrics-based hiring software is currently under investigation by the Equal Employment Opportunity Commission for discriminating against people with disabilities. Even the knowledge-sharing metrics used by companies like Cornerstone to assess elite knowledge workers may reproduce inequity. As Marc Smith, the sociologist from the Social Media Research Foundation, pointed out, “The diversity of your connections is a proxy for your wealth.” In other words, firms that reward their optimally networked employees risk further increasing inequality...

As Zeynep Ton wrote in the Harvard Business Review, companies such as Costco and Trader Joe’s that invest in higher pay, more training, and more convenient schedules bring in far more revenue per employee than competitors that do not. Both companies are Kronos clients. Charles DeWitt, the Kronos executive, said that retailers are better served when they see employees as potential profit centers, and not just as “a big bucket of costs” to be cut. Still, the dominant paradigm remains what Lisa Disselkamp, the Deloitte consultant, calls “the highly optimized system,” one organized around minimizing labor costs. Perhaps you can’t manage what you can’t measure. But the measuring has taken on a life of its own.
You would do well to subscribe to Harper's and read the entire thing. It has given me pause, in light of my obvious affinity for "Lean." What are the proper ethical limits of pursuing the maximization of "operational efficiencies"  -- going all-in "Lean/Six Sigma/Agile" if it entails surveilling and micromanaging the daily lives of the people doing the work? I re-visit my June 20th, 2014 concern:
Recall from Dr. Toussaint's writings? "Manage processes, lead people"? The concerns aired by Simon Head pertaining to HRM, BPR, and CBS reveal evidence that some organizations are moving in the other direction -- using IT to manage people. In healthcare this is precisely the wrong thrust, and will only serve to deepen the cynicism of many critics of HIT and cannot but throw sand in the improvement gears.
What of "Just Culture"? Relatedly, what of a "Talking Stick" ethos? Maybe we don't care, given that the micro-manage-people focus is currently on lower-level workers in retail, fast food, fulfillment centers, delivery services, and lower white collar employee strata, etc.

These UberTopia hustlers won't stop there, though, and, given the increasing cost-reduction imperatives we see loudly touted in healthcare media every day, "Cornerstone OnDemand" et al may well be infiltrating clinical organizations near you in short order to bring in the putative Productivity Treadmill Panopticon.

BTW, see also my prior post "Will Silicon Valley's digerati "solve" healthcare?" Pay specific attention to Evgeny Morozov's iconoclastic book "To Save Everything, Click HERE."

One. That’s what the word “Standard” means -- er, should mean. To the extent that you have a plethora of contending “standards” around a single topic, you effectively have none. You have simply a no-value-add “standards promulgation” blindered busywork industry frenetically shoveling sand in the Health IT gears under the illusory guise of doing something goalworthy.

One. Then stand back and watch the private HIT market work its creative, innovative, utilitarian magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive on customer value (including, most importantly, seamless patient data interchange for that most important customer). You need not specify by federal regulation (other than regs pertaining to ePHI security and privacy) any additional substantive “regulation” of the “means” for achieving the ends that we all agree are necessary and desirable. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, those within other normative vocabulary code sets, and unstructured, e.g., open-ended free-form SOAP note narratives), numbers (integer and floating-point decimal), and images. All things above that are mere “representations” of the basic data (e.g., text lengths, datetime formats, Boolean/logical, .pngs, bmps, .tiffs, .jpegs etc)... 
From my February 2014 post We should not prescribe specific functionality for the EHR other than interoperability and security.”
- John Halamka

More to come...

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