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Monday, September 28, 2015

What exactly is "Leadership," anyway?


I'll be there starting Sunday. There will be Tech and "Thought Leaders" and "Futurists" galore to regale, wow, and inspire us.

On "leaders." I'm sure it's not news to you that we in the U.S. are now in the tediously extended and overwhelmingly melodramatic throes of vetting the myriad candidates for our next change in national political "governance." "Leadership" is probably too strong a word. Hell, even "governance" begs a question. Many of our national "leaders" and those who cyclically propose to succeed them seem increasingly less interested in actual (frequently boring) governance and more interested in endlessly campaigning for positions of authority. At the national level, it seems as though we pay for four incremental years of federal governance, but only really get one. The rest of the time is spent on ever-expanding periods of campaigning, first for the subsequent bi-yearly congressional mid-term election cycle, then for the next Presidential cycle.

Whatever. That will be what it will be. Much of it unfortunately in the form of crass, lowbrow "entertainment."

More broadly, what of "leadership" across socioeconomic and cultural domains writ large? I've reflected on the topic a lot across the years, and written about it here on KHIT a good bit. See, e.g., "If you're 10 feet ahead, you're a 'Leader.' If you're 100 feet ahead, you're a Target." - Brent James, MD, M.Stat, and "The "Talking Stick" and the three-legged stool of sustained, transformative healthcare QI. See also my posts on the 2015 Lean Healthcare Transformation Summit.

"Leadership." We toss the word about cavalierly. We have an entire industry devoted to it. Do we all mean the same thing? Hell, even Forbes is confused.
"I’ve now written several books on leadership for employee engagement, and yet it occurred to me that I never actually paused to define leadership."
Seriously, dude?
What is Leadership?
Kevin Kruse, Forbes Contributor

What is leadership, anyway?

Such a simple question, and yet it continues to vex popular consultants and lay people alike. I’ve now written several books on leadership for employee engagement, and yet it occurred to me that I never actually paused to define leadership. Let’s start with what leadership is not…

Leadership has nothing to do with seniority or one’s position in the hierarchy of a company. Too many talk about a company’s leadership referring to the senior most executives in the organization. They are just that, senior executives. Leadership doesn’t automatically happen when you reach a certain pay grade. Hopefully you find it there, but there are no guarantees.

Leadership has nothing to do with titles. Similar to the point above, just because you have a C-level title, doesn’t automatically make you a “leader.” In all of my talks I stress the fact that you don’t need a title to lead. In fact, you can be a leader in your place of worship, your neighborhood, in your family, all without having a title.

Leadership has nothing to do with personal attributes. Say the word “leader” and most people think of a domineering, take-charge charismatic individual. We often think of icons from history like General Patton or President Lincoln. But leadership isn’t an adjective. We don’t need extroverted charismatic traits to practice leadership. And those with charisma don’t automatically lead.

Leadership isn’t management. This is the big one. Leadership and management are not synonymous.  You have 15 people in your downline and P&L responsibility? Good for you, hopefully you are a good manager. Good management is needed. Managers need to plan, measure, monitor, coordinate, solve, hire, fire, and so many other things. Typically, managers manage things. Leaders lead people...
Better late than never, one supposes. Write the books first, clarify the core definition later. As we used to joke in my radlab in Oak Ridge, "the flowchart comes last."


"A person who directs a military force or unit ... a person who has commanding authority or influence."
Interesting. I was once "a first or principal performer of a group." A "bandleader." Not sure whether "herding cats" counts much. But, seriously, "leadership" goes more to "influence" and "guiding" and "persuasion" than it does to outright "power" and "authority."
See, e.g., Howard Gardner's "Changing Minds" and Robert Cialdini's "Influence."
I recently binge-watched the entirety of the excellent, sobering HBO "docu-drama" series Band of Brothers.

One thing that jumped out at me was the repeated multi-tiered ad hoc examples of "leadership" at every level above the rank of Private. While the military is the prime exemplar of the vertically integrated "command and control" organizational architecture, wherein dereliction and insubordination are dealt with quickly and severely, "leadership" initiative is cultivated and rewarded at every level -- at least in combat theatres. While perhaps "there are no atheists in foxholes," neither are there any bureaucratic "managers."

"If you're 10 feet ahead, you're a 'Leader.' If you're 100 feet ahead, you're a Target."

Love that quote.

Brings me to my next read, just finished. An incredible, bracing, iconoclastic take-no-prisoners book. Scholarly writing with a delightful Lewis Lapham edge.


...I began the writing of Leadership BS with a simple, albeit ambitious, goal: to cause people to rethink, to reconceptualize, and to reorient their behaviors concerning the important topic of leadership. My purpose in all of this is for the next decades of what goes on in workplaces and in people’s careers to be, optimistically, a lot more humane and beneficent than the last decades have been.

I proceed from a historical analogy. Around the turn of the twentieth century, medical practice and medical education in America were pretty dismal. People were hawking untested and unproven “cures,” with their financial success dependent more on their slickness and persuasiveness than on the actual science or medical efficacy of what they were pushing. Almost anyone could practice medicine, as there was no license required. And while there were some outstanding doctors and scientists building the foundations of modern medicine, charlatans and quacks abounded. Many medical schools were proprietary, for-profit entities with little concern with science, lots of concern for financial gain, and little interest in doing evaluations of what they, or their students, were accomplishing (or, more accurately, the harm they were doing).

Into this morass, the Carnegie Foundation sent Abraham Flexner, who was notably a teacher and not a doctor, to survey the landscape of American medical education. His report, published in book-length form in 1910, transformed the training and also the science and practice of medicine. As a result of that report, one-third of the existing medical schools closed, formal licensing for doctors was instituted, and the biomedical, scientific foundation of medical practice— a goal still not perfectly achieved but widely embraced and something that has been responsible for so much progress in the prevention and treatment of disease— was put into place.

The parallels with the current state of the leadership industry are striking. Want to be a leadership coach? You can go to an institute or enroll in one of many programs, of varying quality and rigor, that train coaches with varying degrees of skill, but you don’t have to even do that. You can be a coach tomorrow.

Want to be an expert on leadership? You could get training and exposure to the relevant research literature, but it’s not necessary. If you are persuasive enough, articulate enough, or attractive enough, if you have an interesting enough, uplifting story or some combination of these traits, you are or can be a very successful leadership blogger, speaker, and consultant—consultant— whether or not you have ever read, let alone contributed to, any of the relevant social science on the topic.

To be sure, these days there are many fabulously fantastic people with exceptional credentials and ethics working mightily to improve organizational workplaces and leaders’ careers. But the leadership industry also has its share of quacks and sham artists who sell promises and stories, some true, some not, but all of them inspirational and comfortable, with not much follow-up to see what really does work and what doesn’t. And much like the field of medicine prior to Flexner, what speaks the loudest in the leadership industry seems to be money, rather than evidence-based, useful knowledge. The way leadership gurus try to demonstrate their legitimacy is not through their scientific knowledge or accomplishments but rather by achieving public notoriety— be it the requisite TED talks, blog posts, Twitter followers, or books filled with leadership advice that might or might not be valid and useful.

Pfeffer, Jeffrey (2015-09-15). Leadership BS: Fixing Workplaces and Careers One Truth at a Time. HarperCollins. Kindle Edition.

CHAPTER 8: Fixing Leadership Failures: You Can Handle the Truth

It’s September 2013, and I am giving a talk to alumni and other executives on some of the material covered in this book. About forty people are gathered at the newly opened Vlerick Business School facility in Brussels, Belgium. A hand goes up and an experienced senior executive comments, “I have seen everything you have described and can vouch for its accuracy. But this is depressing, even if it is true.”

In my reply, I acknowledge that what one finds depressing is a relative concept, and that while this individual may find my description of the work world quite sobering, a sentiment I can certainly understand, I don’t. Instead, I say, “I find it even more depressing that talented, earnest, young, and for that matter, not-so-young entrepreneurs and leaders in all types of organizations all over the world lose their jobs and their companies at unacceptably high rates.”

I continue, “I find it depressing that after decades of books, lectures, leadership-development programs, and all the other components of the large leadership industry, virtually every shred of evidence shows most workplaces filled with distrustful, disengaged, dissatisfied, despairing employees. And,” I conclude, forgoing any pretense of political correctness, “I find it depressing that we would want to discuss the state of leadership in organizations from the perspective of what feels good and uplifting, rather than what the evidence shows to be true.”

This executive’s comment is not all that unusual. After a talk about this book to an academic audience in Spain, I get a similar response— the material is provocative and probably true, but not “uplifting.”

The difference between management science and medical science is telling. “Depressing” may be an emotion felt by medical researchers and by practitioners confronted on a daily basis by the inevitable limitations of current treatments, and certainly people would love to be “uplifted.” But “depressing” or, conversely, “uplifting” are almost certainly not how doctors and other medical researchers evaluate evidence or figure out how to make progress in treatment. Averting our eyes from the facts may provide solace, but it does so at the price of progress. There is no theory or evidence that suggests that improvement comes from ignoring bad news, paying inordinate attention to rare, exceptional cases, or from failing to measure base rates for how often something occurs. No wonder medical science has made significant strides in treating many diseases while leadership as it is practiced daily all over the world has continued to produce a lot of disengaged, dissatisfied, and disaffected employees.

So we end where we began, with the pragmatic question of whether all the inspiration and feel-good stories produced over the decades have done any good. This is not a question about competence, motive, purpose, intentions, sincerity, or even hypocrisy (which there is in abundance). It is a simple question about the state of the world of work and leadership after the expenditure of so much time, effort, and money with so few results. Yes, some people would argue that things might even be worse without all these efforts. But holding aside the impossibility of empirically demonstrating the truth of that counterfactual argument, it is a tough argument to accept, given the dismal data on employee engagement, job dissatisfaction, trust in leaders, and career catastrophes.

The discussions about leadership often seem sort of like being under the effect of nitrous oxide (laughing gas) or other forms of mild anesthesia. By leaving people feeling good while somewhat uninformed about reality, the leadership enterprise helps produce people happily oblivious to many important truths about organizational life in the real world. In this zoned-out, semiconscious, blissful state, people are insufficiently prepared for what they will encounter at work and, most important, insufficiently energized to accurately diagnose and change that world of work. That’s because people think everything is just peachy fine, or soon will be. But if the world of work in a few more decades is to look any different— or better— than the one today, people need to understand the world not as we might want it to be, but as it is. To get from one place to another, you need to know as best as you can where you are, where you want to go, and, most important, the obstacles and barriers you will likely encounter en rout
[ibid, pp. 193-195].
Yikes. I bought my wife a hardbound copy for her convenience (so I can quit interrupting her and reading excerpts to her). She's a C-Suite exec at the top of her game, and an astute observer of and adroit survivor of carnivorous corporate politics. She'll dig it. She likely could have written it.

So, what of it, as it goes to things like process QI? Dr. Pfeffer cites Deming:
If leaders are, as everyone I know would admit, inevitably imperfect and impermanent, there are two possible solutions for the problems this fact causes for those who work for such leaders. The first solution is an approach advocated by many leadership-development practitioners and teachers: do a better job of developing, training, educating, and selecting leaders so we change the distribution of the leaders we have in the talent pool from selfish versus selfless, competent versus incompetent, egotistical versus modest, trustworthy versus untrustworthy— you get the picture.

This is a nice sentiment, and one that animates the leadership industry and its many practitioners, but one that, for all of the psychological and social psychological reasons already covered in this book, is not very likely to work, at least on a consistent basis. There is, however, a second approach worth considering, one that grew out of the quality movement; it’s an approach that helps explain why flying in an airplane has become so incredibly safe.

Whenever there is an airplane accident, or for that matter, a number of near-accidents or other problems, the customary response is to try to redesign the plane to make such problems less likely to occur in the future. This may entail changing the controls or the guidance systems, or increasing mechanical or other system redundancies— in short, doing things that make it easier for the people flying and servicing the plane to do the right thing and more difficult for them to screw up. Such an approach is completely consistent with the principles of the quality movement, which promotes fixing the system rather than relying on the skills of individuals— to produce, in other words, an environment in which ordinary, albeit conscientious, people can reliably produce desirable results.

The lesson of W. Edwards Deming and his peers in the quality movement is that relying on individual motivation and acts of great competence is a singularly unreliable way to produce consistently high levels of system performance. Deming argued that if there are performance problems and quality defects, one needs to understand how those problems arise almost naturally as a consequence of how a system has been designed— and then fix those design flaws. Put simply, attack the problems by fixing the system, not scapegoating the necessarily fallible human beings working in and operating that system— whether or not they deserved it.

Inside organizations of all kinds, there are many ways to redesign governance that would reduce the dependence of employee well-being on the vagaries of people’s doing a better job of selecting and training all-powerful leaders. Such solutions mostly entail building work systems that are less leader-dependent, and instead devolve more power to a wider set of organizational constituents, particularly employees. Such systems include employee ownership; building in formalized countervailing power, such as that provided by works councils in some European countries or unions in other places; building employment systems with more distributed power by having people elect their leaders, as occurs in some partnerships; and so forth. With more distributed and balanced power, the ability of a single individual to do remarkably good— or remarkably harmful— things becomes diminished. Interestingly, these approaches seldom get much attention. Instead, we hear more pleas for better leaders— pleas that have produced little improvement in any aspect of workplaces or leader tenure in the past fifty-plus years. But never mind, maybe the future will be better.

In the absence of any sustained movement to create better management and organizational governance systems that rely more on the “wisdom of crowds” and less on the hope that one’s leader is better than average and not overly self-interested, it seems sensible to look out for oneself [ibid, pp. 185-186].
I know the docs all hate the frequently-cited aviation allusion. Beyond that, though, this stuff goes straight to the heart of things like the Lean methodology and David Marx's Just Culture principles. Click here for more on my prior Marx cites. There's also some Maccoby in that post. He is also cited in Leadership BS.
[A]s Michael Maccoby notes in his book The Productive Narcissist, the pioneering innovation that, almost by definition, breaks with convention and reinvents products, industries, and business models requires the kind of disdain for the constraining views of others and persistence in the face of adversity and naysaying that characterize narcissists.  Indeed, Maccoby almost equates visionary leadership with leaders who have at least some reasonable degree of narcissism.

While there is not much research evidence about modesty and its effectiveness as a leadership quality, there is an extensive literature on a very closely related, albeit opposite, concept: narcissism. Studies of narcissism can help us evaluate the usefulness of prescriptions for leaders to be modest and also see the extent to which leaders are narcissistic on the one hand or modest on the other.

Although sometimes considered a form of personality disorder, narcissism and narcissistic behaviors are quite common, particularly among leaders. Michael Maccoby has noted that many of the most well-known and well-regarded CEOs, including Bill Gates of Microsoft, Steve Jobs of Apple, and Jack Welch of General Electric, exhibited narcissistic traits and behaviors. Maccoby also includes John D. Rockefeller; Robert Johnson, the founder and leader of Black Entertainment Television; J. Craig Venter, the CEO of Celera Genomics; and Jim Clark, the founder of Silicon Graphics and the onetime CEO of Netscape among a long list of narcissistic business leaders. Other narcissistic leaders include David Geffen (cofounder of the Dreamworks movie studio), Michael Eisner (Disney), Kenneth Lay (Enron), and many politicians, including Joseph Stalin and President George W. Bush. For all these individuals, attention-seeking and a sense of entitlement nearly define their personalities.

Narcissism has been defined in the psychology research literature as a grandiose sense of self-importance; arrogant behavior or attitudes; a lack of empathy for others; a preoccupation with fantasies of unlimited success or power; belief in one’s special or unique status, including a fixation on associating with high-status people or organizations; an unreasonable sense of expectations or entitlement; and a desire for excessive admiration from others, among other characteristics. Narcissism can be measured by a validated paper-and-pencil measure, the Narcissistic Personality Inventory (NPI). It can also be assessed indirectly and unobtrusively. For instance, one study of the effect of CEO narcissism on companies examined the prominence of the CEO’s picture in the annual reports, the CEO’s use of the first-person singular pronoun (“ I”) in interviews, the CEO’s prominence in the company’s press releases, and the CEO’s compensation compared with the number-two ranking executive’s to assess narcissism. The use of first-person pronouns can be particularly revealing of narcissism, such as CEOs talking about themselves when they should be referring to their companies or executive teams.

You can use these and other similar indicators of immodesty and hubris to help structure your observations of the leaders you encounter, and to help answer the question for yourself: How does hubristic self-absorption affect the careers of people in work organizations? I believe that your own observations can be at least as convincing as any evidence I present. If you become attuned to assessing narcissism as exhibited in natural settings, you can learn a great deal about when, how, and why self-aggrandizement is or is not effective... [ibid, pp. 69-71].
A compelling read, this book.


October 1st. The author was interviewed on KQED's "Forum."


apropos of the military, ran across this Atlantic article this morning:
The Military Isn’t Preparing People for Private-Sector Success
And that’s a good thing: Thriving in business requires a shallow, materialist outlook that is out of place in the armed forces.

Those considered successful in America seem, at least superficially, to cover a fairly broad spectrum: the business entrepreneur, the pop star, the professional athlete, perhaps a surgeon. Yet while their success derives from very different activities, one feature they all share in common is wealth. To be successful in America means to be rich, and much of our culture is monomaniacally focused on getting rich.

There is one major subset of Americans for whom this is not the case, who have not put making money at the center of their lives: service members. And it shows: Many retired service members are not doing well once they enter the private sector. As former Federal Reserve Chairman Ben Bernanke said at a Brookings Institution event last month, “If you go into the military at age 18—versus an identical person who stays in the private sector and takes a private sector job—10 years later, if you leave the military, your skills and wages are probably not going to be as quite as high on average as the private-sector person.” Living as we do in a climate where to say anything that could be vaguely construed as “anti-troop” is anathema, his remarks were quite controversial...
Good piece.

Also apropos of the military...

Couldn't resist. The four-deferments Vietnam war dodger recently insisted that he felt as though he'd actually been "in the military," given that his parents had sent him to a military-themed prep school prior to college. Yeah, Commander-in-Chief / Foreign Policy chops, yeah, forged in the crucible of a dress-up-like-a-West-Point-cadet private high school. Right.

Also apropos of "BS," as I've noted elsewhere:
Why is there so much bullshit? Of course it is impossible to be sure that there is relatively more of it nowadays than at other times. There is more communication of all kinds in our time than ever before, but the proportion that is bullshit may not have increased. Without assuming that the incidence of bullshit is actually greater now, I will mention a few considerations that help to account for the fact that it is currently so great. Bullshit is unavoidable whenever circumstances require someone to talk without knowing what he is talking about. Thus the production of bullshit is stimulated whenever a person’s obligations or opportunities to speak about some topic exceed his knowledge of the facts that are relevant to that topic. This discrepancy is common in public life, where people are frequently impelled—whether by their own propensities or by the demands of others—to speak extensively about matters of which they are to some degree ignorant. Closely related instances arise from the widespread conviction that it is the responsibility of a citizen in a democracy to have opinions about everything, or at least everything that pertains to the conduct of his country’s affairs. The lack of any significant connection between a person’s opinions and his apprehension of reality will be even more severe, needless to say, for someone who believes it his responsibility, as a conscientious moral agent, to evaluate events and conditions in all parts of the world…
Referencing another great book.

BTW: Pfeffer on the military:
Leaders who have come up through the ranks and have done many if not most of the organization’s jobs are much more likely to look out for the interests of those they lead because they have been there themselves. That is one plausible explanation for why, in general, leadership in the military is not just better but why senior military officers typically show a higher level of concern for the well-being of their people than do leaders in many companies. Military leaders come up through the ranks, so they once were in the positions of the people they lead, and therefore have much more empathy for and understanding of their subordinates. Outside succession, and particularly succession by industry outsiders with limited frontline experience, exacerbates the tendency for leaders to not give the interests and well-being of others much priority. [op cit, pp. 166-167].
He goes on to give good discussion of the civilian corporate difference, in particular the leadership liabilities of "outside succession" (e.g., think the likes of a Carly Fiorina).


In my mail today, a postcard conference pitch from my professional society:

Theme and Focus Areas
Leadership at Every Level
We all strive to achieve results, and each of us strives to sustain the results we gain. There are a lot of factors that play into the level of success or failure that organizations achieve, whether it be the culture we work in, how aligned our efforts are, or the ability we have to deal with and mitigate risk. But out of all the factors at play, leadership is among the most critical. Studies show that anywhere from 50 to 95 percent of improvement programs fail. There are differing opinions as to just how high that number is, but also overwhelming consensus that leadership is a key component in avoiding such failures. Leadership through action, leadership with purpose, and leadership at all levels of an organization are critical to achieving and sustaining results.  

The efforts made to embrace and implement lean and Six Sigma methodologies can provide individuals with the tools they need to achieve results. However, sustaining those results is often a challenge that requires commitment, a culture of improvement, and most of all leadership. It requires leadership that goes beyond the top of the organization and spreads out to all levels of it; and it involves leadership that is both nurtured and sustained.
"Leadership," baby. It's not just for breakfast anymore Who can argue with those last two sentences?

Let the ongoing monetization of "leadership" proceed apace. Early Bird registration fee here for ASQ members, a mere $1,195 for the two-day conference.

Speaking of Health IT "Leadership,"


PDF copy here (50 pages). When I'm pressed for time and have too much contending stuff to read, many times I'll do a keyword search of high-priority terms and phrases to get a sense of relative emphasis, and scan a few excerpts prior to subsequently devoting time to close front-to-back study. A quick selective rank-ordered tally here:
  1. "Standards" - 42
  2. "Value" - 29
  3. "Interoperability" - 26
  4. "exchange" - 20
  5. "EHR"  - 18
  6. "mobile" - 13
  7. "usability" - 9
  8. "telehealth" and "seamless" (a tie) - 8
  9. "patient-centered" - 6
  10. "performance" - 4
  11. "governance" - 2
  12. "portal" - 1
  13. "leadership, API(s), HL7, HL-7, FHIR, use case(s), ACO, PCMH" - 0
Interesting. Particularly #13.


The incredible 15-part Steve Brill "Docu-Serial" on Johnson & Johnson and their Risperdal Rx is now complete.


More to come...

Thursday, September 24, 2015

Countdown to ICD-10, and other pending developments

Well, as I write this (with the TV on as Pope Francis addresses the U.S. Congress), one week from today, the transition to the ICD-10 coding system will be required. That news may well be overshadowed by another federal government shutdown, this time over the issue of funding for Planned Parenthood.
SEPT 26th UPDATE: House Speaker John Boehner has announced his resignation, effective at the end of October. It looks like he will prevent the Tea Party hardline wing of the GOP from shutting down the government, given that he controls the flow of legislative proposals that actually get to the Floor.
Plenty of ICD-10 reporting out there these days.
Medscape Medical News
ICD-10: Countdown to a Meltdown, or a Yawn?
Robert Lowes, September 24, 2015
Government rollouts in healthcare haven't enjoyed a good reputation lately.

The website for the Affordable Care Act (ACA), called, went live in October 2013 and then went glitchy. Only after major repairs could Americans sign up for insurance coverage without pulling out their hair. The year before, the switch to the Version 5010 standard for electronic insurance claims delayed payments to some physician practices, which in turn struggled to meet payroll.

These memories darken expectations of the ICD-10 diagnosis codes that debut on October 1 after being damned, denied, and delayed the past several years, according to students of physician reimbursement interviewed by Medscape Medical News. To some, the ICD-10 jitters recall the Y2K scare, when people stockpiled bottled water in fear of civilization-wrecking computer crashes on January 1, 2000. With ICD-10, the favored survival tactic for physicians is obtaining a bank line of credit for 3 to 6 months, if not longer, to cope with interrupted cash flow.

"There's a lot of anxiety about how claims will go through," said Robert Wergin, MD, president of the American Academy of Family Physicians, in an interview with Medscape Medical News. "The experience with makes you a little nervous."

Then again, the worst-case prophecies for Y2K never materialized, and the same could be true for ICD-10...
I recall being in the air on a Delta red-eye enroute from Vegas to Florida to deal with my ailing parents at the moment of Y2K. Picked that flight deliberately.

I hope the ICD-10 transition will be another relative yawn. We probably will not really know for quite a while.

Other news:
Medical Societies Call for Delay of Meaningful Use Stage 3 

Meaningful use stage 3 is not scheduled to start until 2017, but 41 medical societies, including the American Medical Association (AMA), American College of Physicians, and the American Society of Hematology, are calling to delay the start of stage 3, especially given recent changes to Medicare. 

These medical societies are backing Senator Lamar Alexander, who believes the meaningful use program should be paused given the need to improve usability and interoperability of electronic health records. 

"Proper reassessment of the program before implementing the final stage of regulations will help avoid problematic software that physicians and patients will be burdened with for years to come," AMA President Steven J. Stack, MD, said in response to Alexander's calls for delay...
No surprise there. Most of the MU incentive money is already out the door (at ~$32 billion thus far). All that remain are the griping and looming payment penalties for non-compliance.

Also, today, Chapter 10 of the jaw-dropping Steve Brill series.


My latest read.

Yet another look into organizational culture issues of relevance to the health care space (e.g., see my "Talking Stick" post).
How Doctors Tried Not to Behave Like Economists

THE MOOD IN THE LECTURE theater at Harvard Business School was earnest and respectful. Sitting in the rows of seats, arranged in a horseshoe shape around a dais, were some of the most ambitious young people in the world. Attending Harvard Business School typically costs at least $ 100,000, and competition to win places is fierce. 1 The students have sky-high expectations of themselves and speakers who visit that famed lecture hall. And the man chosen to address the students on that day in early autumn 2006 was dazzling

A tall, imposing figure with a craggy face and big ears, Toby Cosgrove, sixty-five, was one of most famous heart surgeons in world. During the first few decades of his career, he had shot to glory in the medical world as a pioneering cardiothoracic surgeon who had operated on more than 22,000 patients and filed thirty patents for medical innovations. But in 2004 Cosgrove was appointed CEO of the mighty Cleveland Clinic in Ohio, one of the biggest medical centers in America, with an operating budget of $ 6 billion and staff of 40,000. The clinic was ranked among the best in America in numerous fields, including Cosgrove’s speciality of heart surgery. It offered cutting-edge treatments at prices that were better than those of most competitors. People from around the world flocked to use its services. It was, in short, a model of how a twenty-first-century hospital should operate, at least in the eyes of Harvard Business School. 

So the students listened with awe as Cosgrove explained how Cleveland Clinic worked. He was a good speaker, who exuded firm, natural authority, leavened by flashes of dry, self-deprecating wit. What most people did not know was that Cosgrove was also dyslexic. In his teens and early twenties he had struggled at school. But he had battled through this handicap to become a surgeon by virtue of ferocious willpower and a photographic memory. “Dr. Cosgrove is a brilliant man, the most ambitious person in the world since Alexander the Great,” Bruce Lytle, a fellow heart surgeon at Cleveland Clinic sometimes joked. “That is good— you need those people to change the world.” 

After Cosgrove finished his speech to the Harvard students, he took questions. The first few were admiring. But then a young, slim brunette woman named Kara Medoff Barnett, who was sitting in the second row of the auditorium, stood up. “Dr. Cosgrove, my father needed mitral valve surgery. We knew about Clevelend Clinic and the excellent results you have. But we decided not to go there because we heard you had no empathy. We went to another hospital instead, even though it wasn’t as highly ranked as yours.”

There was a startled pause. Barnett pressed on, looking Cosgrove in the eye. “Dr. Cosgrove, do you teach empathy at Cleveland Clinic?”

Empathy? Cosgrove was a loss. During his decades-long battle to become a star surgeon against fierce odds, Cosgrove had spent numerous days honing his technical skills. But he had never given much thought to empathy. It sounded hippie, if not self-indulgent. “Not really,” he mumbled vaguely, and switched the subject. 

The next day he left Boston, and tried to brush the incident off. But that odd little encounter kept buzzing through his mind. Dr. Cosgrove, do you teach empathy? Ten days later, it popped into his head again, in the unlikely setting of Saudi Arabia. The top managers of Cleveland Clinic were keen to expand in the Middle East, since it had a pool of wealthy clients. So Cosgrove decided to attend the official opening of a new hospital in Jeddah. To mark the occasion, the Saudi king and crown prince hosted a ceremony, along with many local dignitaries, and the new head of the hospital gave a passionate speech. “This hospital is dedicated to the body, spirit and soul of the patient,” he declared. As he spoke, Cosgrove glanced across to the Saudi king and noticed, to his complete surprise, that tears were rolling down his face. He felt a frisson. We’re really missing something here. He was used to thinking about medicine in dry, technical terms, or a delineated bundle of specialist skills. He did not usually think about the whole “soul.” 

But were specialist skills really enough? The question kept buzzing around in his mind. On paper, Cosgrove knew that Cleveland Clinic was an excellent medical center, or at least it was if you looked at it using the type of mental map that doctors used. There were world-class surgeons, physicians, nurses, psychologists, and physiotherapists; there were divisions of Anesthesiology, Pediatrics, Medicine, Surgery, Pathology and Laboratory Medicine, Post-Acute Care, Regional Medical Practice, Nursing, and Education. To name but a few of the specialist teams. 

But was this what sick people really wanted? Was it the best, most effective, or cheapest way to do medicine? Cosgrove was starting to have doubts. Doctors visualized medicine as a collection of technical skills. Patients did not. When people were sick they did not say “I need a cardiothoracic surgeon” or “Take me to a cardiologist.” Instead they would declare “My chest hurts,” or “I am having a seizure,” or “I can’t breathe,” or “My stomach is in pain,” or simply “I feel unwell.” 

In some sense, that differences in perception exist about medicine should come as no surprise. When anthropologists first started to study non-Western cultures in the late nineteenth century, they realized that different societies view the body and define sickness and health in subtly varying ways. Then, as anthropology expanded in the twentieth century, a sub-discipline emerged called “medical anthropology,” which examines how health is perceived, experienced, and implemented in different communities around the world. This discipline, which is one of the fastest growing areas of anthropology, argues that health is not really a matter of biology, or not just science. It is a cultural phenomenon too. Our physiology might be universal. But concepts of “sickness” can vary between different cultures, and within the same society...

Tett, Gillian (2015-09-01). The Silo Effect: The Peril of Expertise and the Promise of Breaking Down Barriers (pp. 192-195). Simon & Schuster. Kindle Edition.
The author, a financial columnist for The Financial Times of London, holds a doctorate in cultural anthropology. My first boss at HealthInsight in 1993, our "Senior Analyst," Dr. Ruth Moore (our chain-smoking "Ruthie") was a PhD medical anthropologist. She was a delight. One of my all-time favorite writers is David Graeber, a respected "social anthropologist" whose book "Debt, the first 5,000 years" is a learned and witty must-read. You can do the cheapskate free online Cliff's Notes essay version here at "To Have is to Owe." I cited and excerpted his second book "The Utopia of Rules" here back in February.

Gillian's is an interesting book, a very nice read on its own terms, notwithstanding that I found her take on the financial crisis of the late 2000's (a good bit of the book, actually) excessively apologetic and exculpatory. The otherwise innocent cluelessness wrought by organizational siloing explains a lot, but not nearly enough. The FIRE sector (Finance, Insurance, and Real Estate) was and remains overpopulated with avaricious, cynical, corner-cutting, Machiavellian operatives who personify the phrase "Gresham's Dynamic" ("the Bad drive out the Good").  Google "Moral Hazard Principal Agent Problem." 

Bernie Madoff, anybody? Enron? Worldcom? These people took full advantage (some of it overtly criminal) of the lax, increasingly moribund regulatory environment that was an explicit goal of President George W. Bush and Fed Chairman Alan Greenspan and other so-called "conservatives" whose motives were as opportunistic as they were ideological. I've been a student of white collar skulduggery going all the way back to the Equity Funding scandal of the 60's, through the S&L scandal, the junk bond era, the " built-to-flip bubble" years, and, most recently, the subprime-driven Wall Street debacle of the past decade. I worked in subprime as a risk management analyst for a time as well (2000-2005). See my posts "Tranche Warfare" and "The Dukes of Moral Hazard." I read everything by the likes of respected FIRE sector writers Yves Smith, Nomi Prins, Michael Lewis, and Dr. Bill Black, among others.
"In the gap between perception and reality, there's money to be made." - convicted former junk bond king Michael Milken
apropos of the topic here, I also didn't find as much of relevance in The Silo Effect specific to healthcare workforce culture as I'd hoped (no specific mentions of or allusions to "Just Culture" principles, for example). I will have more to say about it. For now, as she concludes Chapter 7 (the only chapter focused on the healthcare space):
...“Pay matters hugely. Our system of pay is one reason we were able to break down silos. You cannot do this with a fee-for-service model,” Lytle said. “Long-held allegiances and habits only change when they have to change. Harvard doesn’t have to change— they are Harvard, with a long history and the largest endowed institute in the world. But we are a not-for-profit institution in a Rust Belt city on the shores of Lake Erie with a declining population. We have to be better and more creative.” 

But the crucial point about Cleveland Clinic, the doctors argued, was that it showed the value of thinking about classification systems. When people inside businesses or government departments were encouraged to reimagine the world— say, by looking at the world from the perspective of consumers, not producers— they could often become more innovative and effective. If journalists were to start organizing their work according to how readers (not reporters) perceived the world, how would that change the media? Or if manufacturers started organizing their departments based on what customers (not salespeople or designers) thought was important, would they sell the same things? The key point, in other words, was that looking at business processes or services upside-down, or back-to-front, could change an institution’s perspective. Or it could if everybody was willing to take a risk, even without knowing where that mental exercise might lead. “A couple of years ago at Cleveland Clinic we thought we could develop a consultancy business by exporting our model— but then we realized that was a stupid idea,” Modic, the head of the Neurological Institute, observed as he sat in his office in May 2013. “The point is that you cannot buy our system for breaking down silos. You have to build it yourself. It is the process of building a new system and talking about it that transforms you.” [ibid, pg 217]
In the Health IT world, we pretty much speak of "silos" in the context simply of "data" opacity -- the EHRs that won't/can't "talk to each other" (my whole "Interoperababble" mess). We give far less attention to functional opacity -- operational siloing that is really the focus of Ms. Tett's book. And, yes, without data transparency you will continue to be bedeviled with functional siloing. But the issues extend beyond data, into asymmetric and frequently toxic interpersonal power relations.

I am reminded of another fine book in my stash, of some relevance here:

The most straightforward cause of strife on the new pastures is tribalism, the (often unapologetic) favoring of in-group members over out-group members. This is going to be a very short section, because there’s little doubt that humans have tribalistic tendencies that promote conflict. Insofar as there is a debate about our tribalistic tendencies, it’s not about whether we have them, but about why. In my view, the evidence strongly suggests that we have innate tribalistic tendencies. Once again, anthropological reports indicate that in-group favoritism and ethnocentrism are human universals. Young children identify and favor in-group members based on linguistic cues. Reaction-time tests (IATs) reveal widespread negative associations with out-group members in adults, children, and even monkeys. People readily favor in-group members over out-group members, even when the groups are arbitrarily defined and temporary. People readily replace racial classification schemes with alternative coalitional classification schemes, but they don’t do the same for classification by gender, as predicted by evolutionary accounts of human coalitional psychology. And there is a neurotransmitter, oxytocin, that makes people selectively favor in-group members. Finally, all biological accounts of the evolution of cooperation with non-kin involve favoring one’s cooperation partners (most or all of whom belong to one’s group) over others. Indeed, some mathematical models indicate that altruism within groups could not have evolved without hostility between groups.
In short, we appear to be tribalistic by nature, and, in any case, we are certainly tribalistic. This is bound to cause problems— though by no means insurmountable problems— when human groups attempt to live together. 

Tribalism makes it hard for groups to get along, but group-level selfishness is not the only obstacle. Cross-cultural studies reveal that different human groups have strikingly different ideas about the appropriate terms of cooperation, about what people should and should not expect from one another...

Greene, Joshua (2013-10-31). Moral Tribes: Emotion, Reason, and the Gap Between Us and Them (pp. 78-79). Penguin Group US. Kindle Edition.
We do well to also triangulate some of these things with some of the "futurism" citations contained in my prior post, too.


My next read.

Ran across this Stanford prof here:
Jeffrey Pfeffer: Do Workplace Hierarchies Still Matter?
A professor of organizational behavior says office power dynamics are part of our DNA
In a world where a junior staffer can tweet to the CEO, the lines that traditionally delineated power and influence have been blurred. So much so, in fact, that when Jeffrey Pfeffer teaches about corporate America's hierarchical power structure, his students often push back. That model of power isn't relevant anymore, they insist. Such 20th-century thinking.

Pfeffer's students are largely millennials — the youngest generation now in the workforce, born between about 1980 and 1992. He says that they, like much of the media, think the traditional power structure in business is changing and that companies are becoming more dynamic and less hierarchical.

They're wrong. "There's this belief that we are all living in some postmodernist, egalitarian, merit-based paradise and that everything is different in companies now," he says. "But in reality, it's not." In fact, in a new paper that explores the notion that power structures haven't changed much over time, Pfeffer explains that the way organizations operate today actually reflects hundreds of years of hierarchical power structures, and remains unchanged because these structures "can be linked to survival advantages" in the workplace. The beliefs and behaviors that go along with them, he writes, are ingrained in our collective, corporate DNA...
I'll be triangulating this take with the likes of Maccoby and David Marx and others. Side note: my take on our current BS'er-in-Chief.

More to come...

Sunday, September 20, 2015

The future of Healthcare Futurism

I have not the slightest doubt that the occupation of "futurism" has a stable future. We all love to speculate about what's to come. Proffer enough prognostications, some of them will turn out to be correct, just by accident.

I first heard of the designation "Healthcare Futurist" when I became aware of the writings and presentations of Joe Flower. I reviewed his first book in my May 2012 post "Let a Thousand Flowers Bloom."

Great guy. Deep and broad knowledge of the healthcare space, and a totally charitable man. I've cited him elsewhere, e.g., November 2014, "A damning Health IT quote from Joe Flower."

He'll be at Health 2.0 in a couple of weeks in Santa Clara, where he'll be a Keynoter for the Sunday symposium. He has a new book out that is well worth your time.


Carlton runs his EKG, and talks to his cardiologist about it — on his cell phone, while sitting on a bench at the park. 

Alicia’s mother is recovering from surgery in her own bedroom. Alicia and the hospital can continuously track how her mother is doing via the cell-phone-sized ICU-style monitor strapped to her mother’s wrist. 

Dexter calls his own personal doctor, whom he has on retainer, for an appointment that afternoon. Dexter is on Medicaid. Eva needs a new hip, and her co-pay will be pretty big. But her employer’s HR department offers her a deal: They will fly her to California; put her up in a hotel; have the hip redone at a top-flight facility; pay her part of the tab, pay for her drugs, her rehab, everything; and throw in a $5,000 bonus — all because the California facility will do it better and at one quarter the price of the local facility. 

Gareth picks up his cane and hobbles to answer the door. He is obese, his joints are inflamed, his lungs seem to be going, his diabetes is out of control, and he still hasn’t signed up for insurance. The woman at the door introduces herself: she’s his own personal nurse case manager, sent over by the hospital after his third appearance at the emergency department in the last month. 

Healthcare tomorrow will look little like healthcare today. The hospital as we know it will deconstruct into something far more varied, personal, and smaller. Prices for many parts of healthcare may drop by 50 percent, 75 percent, or more. Much medical care will happen where you are, not where the doctor is. Many healthcare organizations that miss the twists and turns of adaptation will fail, their ruins absorbed by others...

Section 1: 
The Ideas We can’t get to real change without a solid grounding in the problem. How did we get here? What are the threads and currents and connections of the tangled mess that we are in? Only when we understand that can we see how pulling this thread or that one, remaking a connection or shifting a power flow, will cause the system to fairly rapidly reconfigure itself...

Section 2: The Levers of Change 
There are seven identifiable levers of change in healthcare right now. Each one of them could, by itself, cause significant change. Together they have enormous power, feeding each other. They are: 
  • Shopping 
  • Transparency 
  • Results 
  • Prevention 
  • Targeting 
  • Trust 
  • Tech 
For each “Lever” I first lay out the problem, then identify the emerging solutions specific to each of six groups: 
  1. Purchasers (employers, pension plans, and other large private purchasers of healthcare) 
  2. Consumers (the end users of and eventual payers for the whole system) 
  3. Health plans (the middlemen in the private financing of the system) 
  4. Entrepreneurs, inventors, and investors (people and organizations creating new products to make healthcare work better) 
  5. Providers (the hospitals, physician groups, and health systems who actually provide us the medical care we need) 
  6. Government (federal, state, and local legislators and policymakers who define the ground rules under which the whole system works)
Flower, Joe (2015-07-30). How to Get What We Pay For: A Handbook for Healthcare Revolutionaries: Doctors, Nurses, Healthcare Leaders, Inventors, Investors, Employers, Insurers, Governments, Consumers, You (Kindle Locations 94-156). Kindle Edition.
I am flattered that Joe included me among a group of pre-publication reviewers. It was time well-spent. (And, btw, full-disclosure: when his book was recently released, I bought my own copy. I cite and review works on this blog based on my assessments of their merits. I don't ask anyone for anything.)

My only significant pre-pub observation was that there'd been no deep discussion of the major, indelible role of government and "regulators" more broadly amid the stakeholders. He subsequently fully addressed that. e.g.,
Healthcare is over-regulated. More important, the regulations are a mess. They overlap, and every agency demands its compliance information in slightly different ways, using slightly different definitions of each measurement. Even worse, some regulations contradict other regulations, so that it is not possible to always be in compliance with all regulations...

Regulatory compliance is the fastest-growing sector of healthcare these days, and that’s not good news. The best estimate is that the documentation required of physicians, for instance, has doubled in just the last 10 years. According to a recent study by the federal Institute of Medicine, the average hospital or health system employs 50 to 100 people, at an average cost between $3.5 million and $12 million, just to answer regulatory compliance surveys.

Hospitals and other healthcare institutions are regulated by (among other agencies): 
  • The Centers for Medicare and Medicaid Services (CMS) 
  • State health and insurance departments 
  • The Internal Revenue Service 
  • The National Committee for Quality Assurance (NCQA) 
  • The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations or JCAHO) 
  • The federal Justice Department (for anti-trust issues) 
  • State “Certificate of Need” commissions 
There are many more. When the Office of the National Coordinator for Health Information Technology (ONC) wanted to build a new strategic roadmap for healthcare IT, it had to consult with 35 different federal agencies. And that’s just for health IT...

The Institute of Medicine has suggested scrapping almost all regulations at federal and state levels and replacing them with a standard of 15 core measures...

...Those who run healthcare and those who buy it and pay for it complain about the burden of regulation, but much of that burden has arisen out of the efforts over decades of the powerful leaders of the legacy system to protect their interests. The movement to the Next Healthcare is not largely something that can be dictated by government; instead it is largely the result of existing economic forces interacting and competing more strongly toward normal economic goals: producing real value for the end user for a lower price than the competition. The winners in the legacy system will fight hard by lobbying legislators and regulators at the state and federal level to maintain their privileged positions and the bloated revenue streams that go with them, even as the regulations choke their ability to move forward [ibid, Kindle Locations 5274-5317].
"Carlton runs his EKG, and talks to his cardiologist about it — on his cell phone, while sitting on a bench at the park."

Yeah. That leads me to my current read, by a self-described "Medical Futurist" I cited in my prior post.

This book, written by a young, absurdly smart, tech-savvy physician who also holds a Doctorate in clinical genomics, is much "geekier," focused principally on technology.
Trends That Are Shaping the Future of Medicine
“Don’t follow trends, start trends.” –Frank Capra

The hardest part of the job of any futurist, particularly a medical futurist, is picking up the trends, technologies and concepts that seem to play a major role in the future of medicine and healthcare as extrapolations for the next years based on today’s trends. What makes it truly complicated is the fact that many of these technologies and concepts intertwine and mix together from many perspectives. The use of artificial intelligence is imminent in the world of electronic medical records, as well as advanced robotics or portable diagnostics.

I chose the topics that appear in the next chapters because they demonstrate the most potential to illustrate what I see as future trends. The goal of these chapters is to give you a clear picture about the key steps being taken in technology by keeping the future of medicine in mind.

The anatomy of a trend description

Each trend’s sub– chapter contains basic descriptions about the technology, real– life stories, practical examples, the concepts that determine its use in medicine and healthcare; and possible future directions. Regarding the twenty– two trends, we will move from concepts that are currently available to technologies that are way off in the future.

At the end of each section are scores that meant to give a better understanding of a particular technology’s usefulness:

A score of availability between 1 and 10, where 1 is currently too futuristic a concept while 10 means it is already available.

  • Focus of attention that describes which stakeholder can best take advantage of the trend.
  • Websites & other online resources that keep you in the information loop by following them.
  • Companies or start– ups working on the particular trend and being in the forefront.
  • Books and Movies describing the advantages and disadvantages of the trend or technology.
Trend 1. Empowered Patients
Trend 2. Gamifying Health
Trend 3. Eating in the future
Trend 4. Augmented Reality and Virtual Reality
Trend 5. Telemedicine and Remote Care
Trend 6. Re– thinking the Medical Curriculum
Trend 7. Surgical and Humanoid Robots
Trend 8. Genomics and Truly Personalized Medicine
Trend 9. Body Sensors Inside and Out
Trend 10. The Medical Tricorder and Portable Diagnostics
Trend 11. Growing Organs in a Dish
Trend 12. Do– It– Yourself Biotechnology
Trend 13. The 3D Printing Revolution
Trend 14. Iron Man: Powered exoskeletons and prosthetics
Trend 15. The End of Human Experimentation
Trend 16. Medical Decisions via Artificial Intelligence
Trend 17. Nanorobots Living In Our Blood
Trend 18. Hospitals of the Future
Trend 19. Virtual– Digital Brains
Trend 20. The Rise of Recreational Cyborgs
Trend 21. Cryonics and Longevity
Trend 22. What Will a Brand New Society Look Like?
Bertalan Meskó (2014-08-27). The Guide to the Future of Medicine: Technology AND The Human Touch. Dr. Bertalan Meskó (Webicina Kft.). Kindle Edition.
Love the "AND The Human Touch" in the title. We'll see about that. 
We are facing major changes as medicine and healthcare now produce more developments than in any other era. Key announcements in technology happen several times a year, showcasing gadgets that can revolutionize our lives and our work. Only five or six years ago it would have been hard to imagine today’s ever increasing billions of social media users; smartphone and tablet medical applications; the augmented world visible through Google Glass; IBM’s supercomputer Watson used in medical decision making; exoskeletons that allow paralyzed people to walk again; or printing out medical equipment and biomaterials in three dimensions. It would have sounded like science fiction. Sooner or later such announcements will go from multiple times a year to several times a month, making it hard to stay informed about the most recent developments. This is the challenge facing all of us. 
At the same time, ever– improving technologies threaten to obscure the human touch, the doctor– patient relationship, and the very delivery of healthcare. Traditional structures of medicine are about to change dramatically with the appearance of telemedicine, the Internet full of misleading information and quacks offering hypnosis consultation through Skype; surgical robots; nanotechnology; and home diagnostic devices that measure almost anything from blood pressure to blood glucose levels and genetic data...

My background as a medical doctor, researcher, and geek gives me a unique perspective about medicine’s future. My doctor self thinks that the rapidly advancing changes to healthcare pose a serious threat to the human touch, the so– called art of medicine. This we cannot let happen. People have an innate propensity to interact with one another; therefore we need empathy and intimate words from our caregivers when we’re ill and vulnerable. 

The medical futurist in me cannot wait to see how the traditional model of medicine can be improved upon by innovative and disruptive technologies. People usually think that technology and the human touch are incompatible. My mission is to prove them wrong. The examples and stories in this book attempt to show that the relationship is mutual. While we can successfully keep the doctor– patient personal relationship based on trust, it is also possible to employ increasingly safe technologies in medicine, and accept that their use is crucial to provide a good care for patients. This mutual relationship and well– designed balance between the art of medicine and the use of innovations will shape the future of medicine [ibid, Kindle Locations 73-104].
I remain conflicted about this "art of medicine" stuff. I've thought about it, read about it, and written about it at some length. See, e.g., my December post The art of medicine consists of amusing the patient while nature cures the disease -
I have long been conflicted over the phrase "art of medicine." Is it a dodge proffered as a disavowal of responsibility in the wake adverse outcomes (particularly in light of the relatively loose coupling of cause and effect in clinical science)? Is it legitimately invoked in pushback over what clinicians decry as top-down mandated EBM / "cookbook medicine"? Are the imaginative ("creative?") heuristic leaps of the adroit physician an inescapably necessary and net value-adding component of the diagnostic and healing method? Is that what we mean by "The Art of Medicine?"

On the tx side of things, matters can be a bit more straightforward. One surgeon may have a rep and a record of being a hack and a butcher while another performs sensitive and precise work that can only be described as "exquisite," "artful."

Diagnostics are inescapably far murkier. Symptoms map overlappingly to myriad disorders, and the lexical narrative fluency of patients to describe them and clinicians to subsequently interpret them varies widely.

Get it right and you're a hero. Get it wrong and you may have a MedMal problem. In a world of reduced reimbursements, the relentless creep of encroaching daily time constraints, and ever-more complex technology and medical research findings (not to mention increasingly onerous regulations), simply navigating the numeric digits and the alphanumeric codes easily fills the clinicians' days."
Is "the art of medicine" really all about adept, ongoing deployment of clinical heuristics (skilled inductive leaps of intuition) amid the churning seas of frequently inconclusive "data" and incumbent processes, buttressed by an equally adroit and abiding sense of "empathy"? (Y'know, the "care" part of "health care"?)

Leads me to another book I recently finished.

Cited this book in an earlier post. I have now finished it.

We cannot begin to understand the changing nature of high-value skills without appreciating the hardwired power and importance of human interaction in our lives. “Natural selection mandated us to be in groups in order to survive,” the eminent neuroscientist and psychologist Michael S. Gazzaniga has written. “Once there, we construct our . . . social relationships, with our interpretive minds ever busy dealing with the stuff around us, most of which involves our fellow humans. . . . Those human social relationships become central to our mental life, indeed become the raison d’être of our lives. . . . We now think about others all the time because that is how we are built. Without all those others, without our alliances and coalitions, we die. It was true . . . for early humans. It is still true for us.” 

That is, we are hardwired to connect social interaction with survival. No connection can be more powerful. We can easily forget— living and working in highly developed economies, doing linear, logical, rational thinking all the livelong day— that such activity is not in our deep nature. But whether we recognize our true nature or overlook it, it’s there inside us, driving us. “We are social to the core,” says Gazzaniga. “There is no way around the fact. Our big brains are there primarily to deal with social matters, not to . . . cogitate about the second law of thermodynamics.”

Colvin, Geoff (2015-08-04). Humans Are Underrated: What High Achievers Know That Brilliant Machines Never Will (pp. 36-37). Penguin Publishing Group. Kindle Edition. 
The elevator speech on this book? "Social/group skills, 'empathy' at the forefront, will be principal criteria for employability in the coming world of AI, IA, and job-displacing robotics."

Not sure yet to what extent I buy this sanguine notion. Seasoned "futurists" estimates indicate that nearly half of service sector jobs -- including those in the degree'd "knowledge worker" strata -- are vulnerable to automation in the coming decades. It's useful to recall that the unemployment rate during last century's protracted, enervating "great depression" of the 1930's was 25%.

See my post "The Robot will see you now -- assuming you can pay."

apropos of "Futurism," this might be a good time to consider again the arguments proffered in the intriguing essay "Four Futures."
Much of the literature on post-capitalist economies is preoccupied with the problem of managing labor in the absence of capitalist bosses. However, I will begin by assuming that problem away, in order to better illuminate other aspects of the issue. This can be done simply by extrapolating capitalism’s tendency toward ever-increasing automation, which makes production ever-more efficient while simultaneously challenging the system’s ability to create jobs, and therefore to sustain demand for what is produced. This theme has been resurgent of late in bourgeois thought: in September 2011, Slate’s Farhad Manjoo wrote a long series on “The Robot Invasion,” and shortly thereafter two MIT economists published Race Against the Machine, an e-book in which they argued that automation was rapidly overtaking many of the areas that until recently served as the capitalist economy’s biggest motors of job creation. From fully automatic car factories to computers that can diagnose medical conditions, robotization is overtaking not only manufacturing, but much of the service sector as well.

Taken to its logical extreme, this dynamic brings us to the point where the economy does not require human labor at all. This does not automatically bring about the end of work or of wage labor, as has been falsely predicted over and over in response to new technological developments. But it does mean that human societies will increasingly face the possibility of freeing people from involuntary labor. Whether we take that opportunity, and how we do so, will depend on two major factors, one material and one social. The first question is resource scarcity: the ability to find cheap sources of energy, to extract or recycle raw materials, and generally to depend on the Earth’s capacity to provide a high material standard of living to all. A society that has both labor-replacing technology and abundant resources can overcome scarcity in a thoroughgoing way that a society with only the first element cannot. The second question is political: what kind of society will we be? One in which all people are treated as free and equal beings, with an equal right to share in society’s wealth? Or a hierarchical order in which an elite dominates and controls the masses and their access to social resources?

There are therefore four logical combinations of the two oppositions, resource abundance vs. scarcity and egalitarianism vs. hierarchy. To put things in somewhat vulgar-Marxist terms, the first axis dictates the economic base of the post-capitalist future, while the second pertains to the socio-political superstructure. Two possible futures are socialisms (only one of which I will actually call by that name) while the other two are contrasting flavors of barbarism...
This will soon be a book release.

I first cited it back on June 29th. The "abundance vs scarcity" by "egalitarianism vs hierarchy" matrix.

Also of relevance, my August post "Medical Progress: Looking back, looking ahead." And my July 20th post "AI vs IA: At the cutting edge of IT R&D."

I'm no "futurist." Just an analyst. My quantitative predictive acumen is limited to the deployment of low-multicollinearity multiple regression model suites (pdf) that can profitably forecast which credit applicants will still be around in five years and paying on time.

I Googled "Healthcare Futurist," and "Medical Futurist," etc. (Not sure of the connotative difference between "healthcare" and "medical" futurists). There are a number of them out there. I don't have time to do a "meta-analysis" of their respective and aggregate prognostications. I'm sure I'd find a lot of Venn Diagram overlap.

In politics they'd simply be called "pundits." 

Dr. Michael Burry was a "futurist," I guess (central figure in Michael Lewis' acclaimed book "The Big Short"). He accurately "saw" the calamitous late-2000's future of of securitized subprime mortgages and made huge Bank "shorting" them (I had a foot in that world for a time. See my old posts "Tranche Warfare," and "The Dukes of Moral Hazard").

Back in the healthcare space, at a more down-to-earth operational level, as it pertains to health IT specifically, Dr. Jerome Carter has some nice new "futurist" thoughts up at EHR Science:
The Future of HIT Innovation is Ambulatory

Well, it’s time to start designing new clinical care systems.  MU is winding down, so the yearly certification requirements churn will be ending soon, or at least slowing greatly, which is a good thing for someone jumping into the market. Current vendors have to support users who do continue in MU because, no matter how few users continue, no vendor wants to have a product decertified. In for a penny, in for a pound… Let’s not forget ICD-10. That transition should cause headaches for at least a few months. Every current vendor is bound to MU and ICD-10, and those with mature products have systems that originated when LAN-based client/server was king. As a group, EHR vendors are protected among themselves by a common set of circumstances. However, they are vulnerable to products that play by different rules—those currently in the design stage.

Here a is list of what we have learned in the six years since HITECH took effect:

  • Interoperability still doesn’t work quite right.
  • Care coordination is a real thing, and EHR systems don’t do it well.
  • Disease registries and chronic disease management are important for care quality.
  • Small practices need good products that are inexpensive, easy to implement, learn, and update.
  • HIT with safety issues can lead to poor care and malpractice suits.
  • Clinician productivity should go up, not down, when HIT is introduced.
  • Workflow is important for EVERYTHING.
  • 64-bit mobile systems are powerful enough to run real software.
  • The cloud is a reliable infrastructure component.
How many items in this list would have been considered important when designing an EHR in 10 years ago? Market leaders, both inpatient and outpatient, had products on the market when HITECH went into effect in 2009. If we assume it takes a minimum of three to four years from concept to product to create a viable EHR, then many current EHR systems date back to at least 2005. A lot has happened since then, so these systems have to play technological “catch-up.” But MU and ICD-10 are putting the serious kibosh on that…
Compelling stuff, as always. See also my August post citing Dr. Carter "Are EHRs Obsolete?"


Steve Brill's amazing "Docuserial" expose of the J&J Risperdol Rx scandal continues apace.

People need to go to jail over this.

More to come...