"Health Data Outside the Doctor's Office" - My latest THCB comment

Yeah. My comment:

@BobbyGvegas says:

“In fact, a minority of our overall health is the result of the health care we receive. If we’re to have an accurate picture of health, we need more than what is currently captured in the electronic health record.”
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Minority indeed. Only ~10% by some estimates. Most of the causal and contributory factors are “upstream.” But, beyond the often politically radioactive socioeconomic factors, included in that upstream estimate are the huge sets of “omics,” which many HIT people want to see included in next generation EHRs. Current CHPL certified ambulatory EHRs today house perhaps 3,500 – 4,000 variables or more “under the hood” in the RDBMS tables and schema. Adding “omics” data to those arrays will be problematic absent [1] a transformative shift the the current payment paradigm, and [2] widespread clinician competence with respect to accurately including “omics” data in the dx and tx. A typical 99213 visit today requires a fleeting time-constrained “access/view/update/append/transmit” drive-by of the several hundred (or more) variables that go into the SOAP and progress note (many of which are pro-forma in order to get paid, which goes to point 1). I will soon be 69. I’m a 99213, so this is no abstraction for me.

The cost of “omics” assays is coming down dramatically. Their irreducible analytical and predictive complexity will remain. For Old Coots in Training like me, the “omics” horse is likely largely already out of the barn. Mandating their inclusion, given the age-related pt encounter UTIL may well be a net loser, writ large.
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“Data sharing is a critical piece of this equation. While we need infrastructure to capture and organize this [sic] data, we also need to ensure that individuals, health care professionals and community leaders can access and exchange this [sic] data, and use it to make decisions that improve health.”
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No small undertaking. We need to figure out how move beyond the fundamental “Opacity = Margin” market imperative. I’m midway through the new Schmidt-Rosenberg book “How Google Works” (which I will soon cite and review on my blog re its import for Health IT). While they laud the Google ethos of “Default of Open,” they’re not about to publish their search and ad placement algorithms. They note that such a stance opens them to charges of hypocrisy, but, so be it.

“With a few exceptions, Google defaults to open, and for these exceptions we are often criticized as being hypocritical, since we preach open in some areas but then sometimes ignore our own advice. This isn’t hypocritical, merely pragmatic. While we generally believe that open is the best strategy, there are certain circumstances where staying closed works as well.”

Schmidt, Eric; Rosenberg, Jonathan (2014-09-23). How Google Works (Kindle Locations 1163-1166). Grand Central Publishing. Kindle Edition.

I guess I should have more accurately noted that "omics" data are considered "upstream" only to the extent that they largely remain pretty much "outside the doctor's office." The other principal "upstream" factors include, in addition to socioeconomic and environmental metrics, issues of "lifestyle" All of these latter factors are correlated to a significant degree.

BTW: I'll be attending and reporting on the event below this Thursday.

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I got onto the "How Google Works" book by way of a New Yorker article when the latest issue showed up in my snailmail box the other day.

When G.M. Was Google
The art of the corporate devotional.

...What’s Google’s secret? This is an irresistible question, because Google is the most successful new business corporation of the twenty-first century. Still only fifteen years old, it is worth about three hundred and eighty billion dollars; its revenues are more than fifty billion dollars a year, and around a quarter of that is profit. More than a billion people perform a Google search every month. It’s natural to wonder whether there’s something each of us can do to emulate Google, with directionally similar, if perhaps more modest, results. What makes the Google model especially alluring is that, as Page and Sergey Brin put it in the statement that accompanied their initial public offering, ten years ago, “Google is not a conventional company.” Getting very rich is always fascinating, but getting very rich while proclaiming that you’re breaking the rules about how to run a business is even more so...

Epic is reported to have earned $1.7 billion in 2013. Maybe Google could just buy them and open them up. They could pay cash and never miss the money.

From "How Google Works"

Three powerful technology trends have converged to fundamentally shift the playing field in most industries. First, the Internet has made information free, copious , and ubiquitous— practically everything is online. Second, mobile devices and networks have made global reach and continuous connectivity widely available. And third, cloud computing 10 has put practically infinite computing power and storage and a host of sophisticated tools and applications at everyone’s disposal, on an inexpensive, pay-as-you-go basis...

Today the components are all about information, connectivity, and computing. Would-be inventors have all the world’s information, global reach, and practically infinite computing power. They have open-source software and abundant APIs that allow them to build easily on each other’s work. They can use standard protocols and languages. They can access information platforms with data about things ranging from traffic to weather to economic transactions to human genetics to who is socially connected with whom , either on an aggregate or ( with permission) individual basis. So one way of developing technical insights is to use some of these accessible technologies and data and apply them in an industry to solve an existing problem in a new way. Besides these common technologies, each industry also has its own unique technical and design expertise. We have always been involved in computing companies, where the underlying technical expertise is computer science. But in other industries the underlying expertise may be medicine, mathematics, biology, chemistry, aeronautics, geology, robotics, psychology, logistics, and so on...

Schmidt, Eric; Rosenberg, Jonathan (2014-09-23). How Google Works (Kindle Locations 176-180, 972-2980). Grand Central Publishing. Kindle Edition.

Recall my earlier post citing Dr. Jerome Carter's "EHR Science."

Looking at clinical care and its computing needs, I see requirements that are distinct when compared to standard business computing. Clinical data are varied and numerous. Clinical work consists of interacting with patients to obtain information, consulting information sources  (e.g., chart, guidelines, articles, other clinicians), making decisions, recording information, and moving on. Support for clinical work requires large, searchable data stores, fast networks, sophisticated communications functionality, and portable computers capable of displaying text, pictures, sound and video. Tablets and smartphones are the first computers to meet all of these requirements.

Writing for mobile means stepping back from web and client/server applications and being willing to see a problem purely from the standpoint of mobile computing; that is, adopting a “mobile first” attitude.

Mobile first requires a willingness to rethink past approaches. At the top of the list is use of cloud capabilities. Like mobile computers, the cloud is a new way of doing things. Building mobile applications that link to cloud storage and use APIs to interact with other applications is a new way of delivering functionality. There is no reason to have local terminology services if they can be obtained via a cloud application. The same is true of workflow engines or another service that supports clinical work. Mobile first also means not taking a client/server app and putting a mobile face on it. That will not work any better than putting a browser interface on a standard desktop app. It might work to some extent, but the original design limitations will show through.

Until the 64-bit chips arrived, the amount of computing power in mobile systems made them useful only for limited applications. However, Apple has shown in its A8X chip that tablets and smartphones are rapidly gaining sufficient computing power and communications capability to make serious clinical applications possible in a way that has never existed–and this is only the chip’s second generation! The fourth generation will appear in 24 months, if Apple sticks to form. What will those systems be capable of doing?

How many EHR vendors will bite the bullet and start serious mobile-first projects? Few, I imagine, because if the past is prologue, most will cling to the prevailing wisdom that mobile devices are not real computers. And we know how that story ends…

WEDNESDAY MORNING UPDATE

 Finished "How Google Works" yesterday afternoon. A fun read. A few of the authors' closing thoughts:

We see most big problems as information problems, which means that with enough data and the ability to crunch it, virtually any challenge facing humanity today can be solved. We think computers will serve at the behest of people— all people— to make their lives better and easier. And we are quite sure that we, as a couple of Silicon Valley guys, will come under a lot of criticism for this Pollyannaish view of the future. But that doesn’t matter. What matters is that there is a bright light at the end of the tunnel.

There are solid reasons underlying our optimism . The first is the explosion of data and a trend toward the free flow of information. From geological and meteorological sensors to computers that record every single economic transaction to wearable technology (such as Google’s smart contact lenses) 210 that continuously tracks a person’s vital signs, types of data are being collected that simply have never been available before, at a scale that was the stuff of science fiction only a few years ago. And there is now practically limitless computing power with which to analyze that data. Infinite data and infinite computing power create an amazing playground for the world’s smart creatives to solve big problems.

This will result in greater collaboration among smart creatives— scientists, doctors, engineers, designers , artists— trying to solve the world’s big problems, since it is so much easier to compare and combine different sets of data. As Carl Shapiro and Hal Varian note in Information Rules, information is costly to produce but cheap to reproduce. So if you create information that can help solve a problem and contribute that information to a platform where it can be shared (or help create the platform), you will enable many others to use that valuable information at low or no cost. Google has a product called Fusion Tables, which is designed to “bust your data out of its silo” by allowing related data sets to be merged and analyzed as a single set, while still retaining the integrity of the original data set. Think of all the research scientists in the world working on similar problems, each with their own set of data in their own spreadsheets and databases. Or local governments trying to assess and solve environmental and infrastructure issues, tracking their progress in systems sitting on their desks or in the basement. Imagine the power of busting down these information silos to combine and analyze the data in new and different ways...

And the advent of networks is giving rise to greater collective wisdom and intelligence . When reigning world champ Garry Kasparov lost his chess match to IBM’s Deep Blue computer in 1997, we all thought we were witnessing a seminal passing of the torch. But it turns out that the match heralded a new age of chess champions: not computers, but people who sharpen their skills by collaborating with computers. Today’s grandmasters (and there are twice as many now as there were in 1997 ) use computers as training partners, which makes the humans even better players. Thus a virtuous cycle of computer-aided intelligence emerges: Computers push humans to get even better, and humans then program even smarter computers. This is clearly happening in chess; why not in other pursuits?

Schmidt, Eric; Rosenberg, Jonathan (2014-09-23). How Google Works (Kindle Locations 3358-3390). Grand Central Publishing. Kindle Edition. 

Think "Watson." That latter paragraph also goes straight to Dr. Weed, et al. See, e.g., my earlier post "Back down in the Weeds': A Complex Systems Science Approach to Healthcare Costs and Quality." And, my first post on Larry Weed, blogged nearly two years ago: "Down in the Weeds'."

Continuing with Eric Schmidt and Jonathan Rosenberg:

The future’s so bright…

It is hard for us to look at an industry or field and not see a bright future. In health care, for example, real-time personal sensors will enable sophisticated tracking and measurement of complex human systems. Combine all that data with a map of risk factors generated by in-depth genetic analysis , and we will have unprecedented abilities (only with an individual’s consent) to identify and prevent or treat individual health issues much earlier. Aggregating that data can create platforms of information and knowledge that enable more effective research and inform smarter health-care policies.

Health-care consumers suffer from a dearth of information: They have virtually no data on procedural outcomes and doctor and hospital performance, and often have a hard time accessing their own health data, especially if it is held by different institutions. And pricing for medical services, medicine, and supplies is completely opaque and varies widely from patient to patient and facility to facility . Just bringing even a basic level of information transparency to health care could have a tremendous positive impact, lowering costs and improving outcomes... [ibid, Kindle Locations 3391-3399]

An excellent book. (It's only $3.75 in Kindle edition at Amazon.) I share their optimism. Guardedly. The comments are piling up in the Health Care Blog post that launched this one: "Health Data Outside the Doctor's Office." Check them out. Lots of cynicism out there, much of it openly hostile.

Here's one of the better ones.

One answer I have for the cynics can be found in my recent post "Physician, Health Thy System."

We also do well to stay mindful of the thoughtful caveats proffered in Nicholas Carr's excellent book "The Glass Cage," a topic of my October 27th, 2014 post. See also my citation of Simon Head's book "Mindless: Why Smart Machines Are Making Dumber Humans."

No shortage of diligent and cautious work to be done in the Health IT space. No shortage of dots to be firmly connected. We will need legions of Schmidt's and Rosenberg's "smart creatives" at their best.

CODA

Not As Loony As It Sounds
Google’s “impossible" plan to beam Internet from solar-powered balloons is actually working. Here’s how.  

The majority of people in the world lack access to the Internet. Either they can’t afford a connection, or none exists where they live. Of all the efforts to bring those people online, Google’s “Project Loon” sounds like the most far-fetched. At the secretive Google X labs, it’s a moonshot among moonshots.

When the search company announced in June 2013 that it was building “Wi-Fi balloons” to blanket the world’s poor, remote, and rural regions with Internet beamed down from the skies, expert reaction ranged from skeptical to dismissive—with good reason. The plans called for Google to put hundreds of solar-powered balloons in the air simultaneously, each coordinating its movements in an intricate dance to provide continuous service even as unpredictable, high-speed winds buffeted them about the stratosphere.

“Absolutely impossible,” declared Per Lindstrand, a Swedish aeronautical engineer and perhaps the world’s best-known balloonist, in an early Wired article about the project...

AFTERWORD

"Who could have conceived that the Information Super Highway would usher in a new Dark Age; a return to blind faith over science, cant over reason?"

The unilateral rejection of facts may be the ultimate metaphor and irony of the Information Age; the more official the source the less likely it is to be believed.

Skepticism is as old as king and country. History itself has been aptly described as an argument un-ended. But there is a profound difference between revisionist history based on new evidence and evolving social mores and the rejection of facts.

In our digital world, all the accumulated knowledge of human history is available in the palm of our hands. But intermingled with hard-won truths are half-baked theories and outright lunacy—decorated with footnotes, graphs, pie charts, and citations from credentialed “experts”—proving that the Earth is warming, the Earth is cooling, or the Earth is flat.

If you seek it, you’ll find it. That’s the problem.

We are overwhelmed with data from every quarter, and our capacity to filter fact from fraud is limited. But the web never rests. Men and women of good intent who simply seek “the truth” upon which to base their opinions find themselves awash in folderol.

No longer confident in any single source for simple truths, more and more of us today are choosing to believe what we are predisposed to believe, period. Contravening facts are dismissed as lies or propaganda.

In a more circumspect time Daniel Patrick Moynihan famously said, “You are entitled to your own opinion, but you are not entitled to your own facts.” In the dotcom world we all have our own facts...

From The Facts About Ferguson Matter, Dammit
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More to come...

The ultimate population health "Upstream" issue?

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

See also my post "The Next Anasazi ruin?" 

From the NY Daily News:

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

Climate change isn't just worrisome for the Earth.

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

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

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

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

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

"Understanding and characterizing this threat and educating the medical community, public, and policy makers are crucial if the health of the world's population is to continue to improve during the latter half of the 21st century," they said.

Yeah, but at least the North Slope Point Barrow Pino Noir should be excellent. /s

apropos, see my 2008 post "0.0143%"

From "The Upstream Doctors"

More than 2,400 years ago, Hippocrates, the father of Western medicine, opened his classic On Airs, Waters, and Places with this advice:

Whoever wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces for they are not at all alike, but differ much from themselves in regard to their changes. Then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality. We must also consider the qualities of the waters, for as they differ from one another in taste and weight, so also do they differ much in their qualities. In the same manner, when one comes into a city to which he is a stranger, he ought to consider its situation, how it lies as to the winds and the rising of the sun; for its influence is not the same whether it lies to the north or the south, to the rising or to the setting sun. These things one ought to consider most attentively, and concerning the waters which the inhabitants use, whether they be marshy and soft, or hard, and running from elevated and rocky situations, and then if saltish and unfit for cooking; and the ground, whether it be naked and deficient in water, or wooded and well watered, and whether it lies in a hollow, confined situation, or is elevated and cold; and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking and eating to excess, and given to indolence, or are fond of exercise and labor, and not given to excess in eating and drinking.

 Hippocrates and a long line of standard-bearers who have followed him have called for an approach in medicine that is capable of appreciating and addressing the social context of health.* I share the hope that all patients and professionals within the health care system better understand this.

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

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More to come...

#Data4Health San Francisco listening session

Much to reflect upon. A natural follow-on from my prior post. Props to RWJF for sponsoring this listening roadshow.

I responded immediately to the post-conference Survey Monkey questionnaire. My free-form responses:

9. What did you think of the breakout topics?

They were fine, as far as they went. Severe time constraint, given the breadth and complexity of the topic. A lot of what I heard discussed really just falls under the category of "Upstream" issues. We will also need to more forcefully address going forward problems of "data quality," -- "accuracy," and the potentially damaging implications of its insufficiency.

10. Did you learn something you can use after the meeting?

Beyond the problems with raising public awareness, a principal takeaway for me is just how far we in the space have yet to go in clarifying fundamental topical definitions. And, the reinforcement of the fact that I seem to really have lost the pedantic fight to preserve the lexical reality that "Data ARE"! Writing "data IS" in a refereed scientific publication is the faux pas equivalent of farting out loud during a plenary session (beyond the fact that it would never get past the editors).

13. Do you have anything else to share you didn't get the chance to?

I will be summarizing my reflections on my blog. Haven't had time yet. Though, I wanted to raise the example of the work now being done at Google Research with their "Google Fusion" initiative, which seeks to surmount the heterogeneity of myriad "big data" formats in the service of structured data merging / synthesis for improved analytics.

Finally, I commend you for this important effort. Thanks to everyone involved.

On the "Upstream" thing. See my prior posts “When it comes to health, your zip code matters more than your genetic code” and "The ultimate population health "Upstream" issue?"

And, below, from my August 13th post:

On the Google Fusion thing:

The overarching goal of structured-data research at Google is to build tools that enable a rich ecosystem of structured data on the Web. To fuel such an ecosystem we need to build tools for discovery, extraction, annotation, sharing, querying, integration, visualization and publishing of structured data sets.

Google Fusion Tables lies at the center of these efforts, offering a tool for data owners to easily upload, query and share data sets. Once the data is uploaded to Fusion Tables, the user can query the data, find related data sets that other users have made public and combine multiple data sets. Users can also create compelling visualizations easily and publish them on the Web. Fusion Tables has been used by a wide variety of users (see our gallery), most notably by journalists and in crisis response.

In our efforts to enable discovery of structured data sets on the Web we developed the WebTables System that extracts the HTML tables that contain valuable data. We extracted a corpus of over 150 million high-quality tables and have developed methods for searching tables in response to queries. In a previous line of work we developed techniques for tapping the content stored in databases behind forms, known as the deep web (or the invisible web). Our research has produced methods for automatically analyzing web forms and submitting meaningful queries to them, to obtain HTML pages that can be inserted into the Google index.

Worth your time to ponder the possible utility in the healthcare "Big Data" space.

Below, some shots I took:

Conference moderator Ivor Braden Horn, MD, MPH

Nice turnout.

RWJF's awesome Mike Painter, MD, JD

HHS's Karen DeSalvo, MD, MPH, MSc had to remote in.

Andrew Rosenthal of Jawbone touted their products' utility for personal health data.

Above, Jawbone Cloud data showing a huge spike in sleep disruption during the recent Napa earthquake.

I'm not a big Jawbone fan. I bought three a few of years ago, one for me, one for my wife, and one for my daughter. Mine and my wife's both went bad in short order. More hassle than it was worth to try to get support service. I hope they've improved their products. I now have a FitBit. It's not a whole lot better. Moreover, there's some troubling news on the quantified self wearables front. See my post "Big Data" and "Surveillant Anxiety."

apropos, I've just been asked to read and review Vik Khanna's irascibly iconoclastic new book,

My favorite fitness app story is that of an acquaintance who told me how the FitBit had improved his life, prompting him to walk more at work and even have his employer provide him with a standing desk. This would all be a very positive step for the many Americans who move too little and sit too much, but this guy is one of the fittest people I know, a physician and an avid cyclist. His habits have already lowered his manageable health risks as low as they can go; using a FitBit isn’t going to change them further. For him, as for many people, tidbits like the FitBit are toys that entertain. I don’t know anyone who needed a FitBit less. On the flipside, there is not much evidence that apps, gadgets, and websites are really having much of an impact on the health of anyone who really needs to find a way to change. Why is that? Because if you are not internally motivated to succeed, a digital toy will not take you there.

The toys, apps, and websites that we want to do the work for us are the electronic equivalent of unused treadmills and weight machines currently functioning as expensive clothes hangers in basements across the country. Health success doesn’t start with trivia such as “Which running app do you use?” It starts with fundamentals, such as “Do you run [substitute the exercise of your choice] at all?” And, if you don’t, why don’t you? Because somewhere along your road in life, people stopped telling you it was important to do so and that is was okay not to, that it was your choice. Well, see, what happens when you make a lot of bad choices it creates an opportunity for government and institutions that want your money and obedience to come in and start to control your choices. When you start acting like a sheep, someone is going to eventually shear you.

Maybe someday all the hype about wearables will translate into something beyond making money for the people who make the devices and their related apps. But, until then, the wearables you need to invest time and money in are your attitude, your strategy, and how you wear them for the world to see. Funny thing about self-image and self-respect… the people I know who carry themselves with the most confidence and poise don’t use any of this stuff. They stick to the basics, the indispensables. Everything else is just gravy.

Vik Khanna. Your Personal Affordable Care Act: How To Avoid Obamacare (Kindle Locations 317-335).

Vik recently threw some serious cold water into the comments at the THCB post "Health Data Outside the Doctor's Office."

"While there are an enormous number of uses for the data that we can imagine and many more we cannot yet anticipate…” 

This is a fancy way of saying we have not decided how we will use these data to manipulate people, scare them, control them, and make them come to believe that, contrary to the opening of this post, the government and its private sector enforcers, really are your health salvation, because, to paraphrase Deep Throat, that’s where the money is. There is no profit in leaving people alone. 

You need no data about me and how I live my life. You are entitled to nothing that I do not want to share with you voluntarily. The federal government used to gather data the very old-fashioned way, by doing surveys. Is there any evidence that we did not get useful information that way? And, even if it was less than ideal, was it so deficient that sacrificing privacy, consent, and voluntary participation are worth the price of admission to this brave new world of “we need all the data we can get?” Al Lewis and Granpappy Yokum above have it nailed exactly right. 

Now, the data geeks have all taken over and want to bamboozle the rest of us into believing that their technology-and-data-are-magic-fairy-dust mythology. The shroud of benevolence obscures a more subversive agenda. Bureaucrats and technocrats never do things that do not serve their own interests first: bigger budgets, longer titles, tenure (in the case of academics), etc. 

How I eat, exercise, work, enjoy myself, is none of your g.d. business. And neither is how a create a culture of health in the unit that matters the most…my family. 

It is long past time for Americans to tell government bureuacrats [sic] to take a hike...

I am as disdainful and distrustful of big philanthropy as I am of big government. In my view, big philanthropy is one of the government’s private sector enforcement tools because of the facade of benevolence that it projects. In reality, there is a revolving door between big government and big philanthropy leaders, and, even more important a long history of the two groups playing footsie with each other while they all accrue more power, more money, and more authority over the lives of individuals.

I would tell people to openly and vigorously reject cooperating with your initiative.

Ouch. Tell us how you really feel, Vik.

Toward the end of his book, Mr. Khanna addresses the Upstream:

Acknowledge explicitly that the healthcare industry cannot fix social and community dysfunction. Medical care cannot make up for lousy schools (also an area in which there is too little competition and efficiency and too many bloviating bureaucrats), broken families, churches with pastors and priests who break every commandment they preach from the pulpit, and communities with no economic prospects. Medical care will not fix someone who does not respect himself. 

Fund and advise communities on how to make their environments safer for cyclists, runners, and walkers. And, I don’t mean just create lanes, which are a good start. Fund creation of entire networks of parks, greenways, and alternative routes for getting around 24/7, and then pay for the police to patrol those areas and keep them safe. 

Fund health and physical education in every school in America from pre-k through graduate and professional school, and make schools compete for grant money. How is it possible college students arrive at that stage of life not knowing how to take care of themselves? 

This morass is our fault. It is the natural cascade of adversity that results when individuals largely fail to exercise their personal will in a positive manner, and we invest too fully and too naively in professions and industries that have motivations and incentives antithetical to our own. Our transformation into an information culture actually worsened the malady. We are so conditioned to success at the speed of a search engine that, like that person who aspires to retire early, but refuses to save or invest, we’ve forgotten to manage the fundamentals. First, that every healthy lifestyle decision you make today, from diet and exercise to outlook and mood requires thought and an exertion of will. Even in the age of Google, your choices matter, and choosing, not just wisely, but strategically, is an option available to most people. Healthy lifestyle is a lifelong pursuit that requires modification and flexibility as you age and your circumstances change. [op cit, Kindle Locations 3019-3037]

More on his book later.
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JASON UPDATE

From a 3rd JASON Report (pdf).

Data for Individual Health

Executive Summary
Introduction

The promise of improving health care through the ready access and integration of data continues to draw significant national attention and federal investment. Information technology is rapidly expanding this data universe beyond traditional information associated with health care providers to embrace information in the larger spheres of health and wellness. This includes not only electronic health records (EHRs), but also personal health records (PHRs) and sources such as environmental data and social media data, some of which may be related only indirectly to the delivery of health care. To date, federal investments in health data infrastructure development, through mechanisms such as the Centers for Medicare and Medicaid Services (CMS) Medicare and Medicaid Electronic Health Record Incentive Program, have focused on the medical care of individuals. This report discusses how to expand this vision, with a focus on the health of individuals and the development of a Learning Health System...

0. 1.3 Summary Today, the delivery of health care moves in a linear fashion, proceeding from preventive medicine, to diagnosis, to treatment, and ultimately to outcomes. This process is informed by clinical research, but there is an inadequate feedback loop between health care outcomes and clinical research, reducing opportunities for further learning in this system. Additionally, population health research and community engagement are not adequately connected. A “Learning Health System” would connect the medical system with broader societal inputs, creating important links between health and wellness and health care. This concept highlights natural roles for EHRs and PHRs, but also points to a level of data access, integration, and scalability that goes well beyond the interoperability of EHR systems...
1.  
2. 1.5 Data Associated with Health
   

   In extending the ideas of the JASON-proposed architecture to the broader realm of health, it will become necessary to expand greatly the types of data that can be ingested and analyzed. In addition to the traditional data associ­ated with health care (e.g., EHR data), it will also be necessary to assimilate data from PHRs. These include, for example, data from personal health devices, patient collaborative networks, social media, environmental and de­mographic data, and the burgeoning data streams that will soon become available through progress in genomics and other “omics.” Despite the pro­ fusion and complexity of new data sources associated with personal health, the architecture for a learning health system would look essentially the same as that proposed by JASON for EHRs except that the data layer must also encompass these highly diverse forms of personal health information. The requirement for interoperability through the adoption of open APIs becomes even more critical here; without this interoperability it will be extremely difficult to scale up today’s health information technology (IT) systems to assimilate and analyze these new data sources...

I study and reflect on all of the JASON stuff. I'll hold my fire on this one until I've fully digested it.

Another of my tweets.

Obtuse analogy? Where do "data" ("do," not "does") fit into concepts such as the (controversial phrase) "art of medicine"? Are we subtly yet significantly more than the sum of our "structured data"?

Philosophia sana in ars medica sana?

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UPDATE: YET ANOTHER ONC HEALTH IT PLAN

Overview
Improving the secure availability and use of health information allows individuals to take ownership over their health, partner with their health care providers, and improve their quality of life and health. It strengthens the delivery of health care and long-term services and supports, and allows public health agencies to detect, track, manage, and prevent disease outbreaks. Information also fuels research and innovation, spurring advancements in scientific discovery. 

Health information technology (health IT) allows individuals and health care entities and providers, home- and community-based supports, and public health entities to electronically collect, share, and use health information. The term “health IT” includes a wide range of products, technologies, and services, such as electronic health records (EHRs), mobile and telehealth technology, cloud-based services, medical devices, and remote monitoring devices, assistive technologies, and sensors.

Federal agencies provide direct care and health insurance, protect public health, fund health and human services for certain populations, invest in infrastructure, develop and implement policies and regulations, and advance groundbreaking research. Given this range of activities, the federal government is also positioned to improve health, health care, and reduce costs through the secure use of information and technology. 

The Federal Health IT Strategic Plan 2015-2020 (Plan) identifies the federal government’s health IT priorities. While this Plan focuses on federal strategies, achieving the vision and goals requires collaboration from state, local, and tribal governments. Efforts by health care entities and providers, public health entities, payers, technology developers, community-based nonprofit organizations, home- based supports, and academic institutions are also essential.

Link to the full pdf report here.
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More to come...

More on the "Upstream." Lead in the water supply.

ScienceBasedMedicine.org has a compelling analytical commentary up on the Flint, Michigan water contamination travesty.

...For those of you who haven’t heard of it yet, the Flint water crisis refers to the ongoing contamination of the tap water in Flint, MI with unacceptably high levels of lead that resulted from change in its water supply nearly two years ago to Flint River water. Because river water is more corrosive than the previous supply that came from Lake Huron (why I’ll explain later) and Flint river water was not properly treated to decrease that corrosiveness, the new water leached lead from old pipes. This resulted in the contamination of the drinking water with dangerous levels of lead in many homes in the city. In addition, there has been a marked increase in the number of cases of Legionnaires’ disease thought to be linked to the new water supply...

A lengthy, thorough piece on an egregious episode of criminal negligence and utter moral indifference perpetrated by Michigan government officials -- starting with Michigan Governor Rick Snyder.

My Photoshop reaction.

Health impacts of the "Upstream," anyone? More on the "Upstream" here as well.

THE HITS JUST KEEP ON COMIN'

Flint children never had a fair shot, even before lead poisoning

On one level, the Flint lead poisoning scandal is about a state mismanaging a city under financial duress and moving the city to a water supply that turned out to be unsafe.

But on another level, it's also about something deeper: the vulnerabilities kids face when they grow up in poverty. They are more likely to have lower test scores, become teen mothers, and experience violent crime. And it's not just a lack of opportunity: A recent study found that the stresses of poverty actually stunt brain development.

Add to that lead poisoning — which also stunts growing brains — and that's what you have in Flint, Michigan...

Could What Happened in Flint Happen Anywhere?
Other U.S. cities, particularly in the Northeast and Midwest, could face the same water crisis because millions of utility lines contain lead, a potent poison.

Flint’s crisis with drinking water contamination has been cast as a unique series of fumbles and cover-ups. But the Michigan city’s plight also illustrates a much wider concern: Millions of Americans drink water that flows through lead pipes, fittings, and solder, most installed before the 1970s.

Lead pipes can be found in much of the U.S., but surveys show they are concentrated in the Northeast and Midwest. Nobody really knows how extensive they are today: A 1990 study estimated that 3.3 million utility service lines contain lead—plus twice as many connecting pipes, and countless amounts of lead solder. In addition, many homes have plumbing that contains the hazardous metal.

If utilities don’t carefully balance water chemistry and treatment methods, and if regulators don’t enforce the rules, lead can leach from utility pipes and household plumbing systems and wind up in people’s water. That’s what happened in Flint. A decade ago, it happened in Washington, D.C., too. About 640,000 District of Columbia residents were exposed to lead when changes in disinfection chemicals allowed lead to leach from pipelines.

And health experts warn that the same crisis could happen again elsewhere, especially as local and state public health budgets shrink...

Does The EPA Bear Responsibility For Flint?

A blame game has erupted over the lead-ridden drinking water in Flint, Michigan. For weeks, residents, politicians, and observers across the country have been asking: Who is responsible for this public health catastrophe?

Politically, blame is polarized. Progressives have taken aim at Michigan’s Republican governor, Rick Snyder, who they say failed to recognize through his state environmental agency that Flint’s water was unsafe. Meanwhile, some conservatives have targeted the Democratic emergency manager of Flint, who they say was ultimately responsible for switching the city’s water supply to the highly suspect Flint River.

The most controversial culprit, however, is the federal Environmental Protection Agency. Long before the crisis erupted, an EPA employee sounded the alarm about a serious lead problem in Flint’s drinking water system. But his higher-ups declined to make that information public, and instead tried behind the scenes to get the Michigan Department of Environmental Quality to take action to solve the problem.

Now, many insist the the EPA should have gone public with what it knew. “With a clear mission to protect human health and the environment, the EPA must be held to the same standard of accountability as state agencies,” the Detroit News wrote in a scathing editorial last week. Indeed, it seemed perplexing that the EPA would sit on troubling information about a potentially poisoned water system in a city of nearly 100,000 people. Why on earth would the EPA do that?...
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[T]he nightmare in Flint reflects the resurgence in American politics of exactly the same attitudes that led to London’s Great Stink more than a century and a half ago. - Paul Krugman, Michigan's Great Stink

Flint, Michigan's water crisis: what the national media got wrong

...Who's really responsible for the Flint water crisis

Many national media reports would have you believe that the crisis began in April 2014, when the city started drawing its water from the Flint River. They'd also have you believe that the crisis was the fault of the locally elected officials who made a catastrophic decision, not to mention city residents who did not hold their leaders accountable.

The stage was set on March 16, 2011, when Michigan Gov. Rick Snyder signed Public Act 4. This measure broadened an earlier law that provided an "emergency financial manager" for financially distressed cities and school districts. Under the new law, "emergency financial managers" became "emergency managers" with the power to cancel or renegotiate city contracts, liquidate assets, suspend local government, unilaterally draft policy, and even disincorporate. (It is worth noting that Michigan emergency managers have done all of these things except disincorporate, which was entertained by a manager in the city of Pontiac.)

The need for an emergency manager was determined by a series of highly subjective criteria. Almost every city that got one was a poor, African-American-majority city devastated by a shrinking industrial sector: Flint, Pontiac, Detroit, Highland Park, Benton Harbor, and so on.

Flint was one of the first cities to be assigned an emergency manager in 2011, and over the course of four years had four such managers.  One of the first manager's first acts was to suspend local government, and this remained essentially in force until the departure of the last emergency manager in 2015. Even today, Flint is under the scrutiny of a "transition advisory board" that has veto power over any local decision, and that has frequently overstepped its professed limited mandate to assure fiscal restraint.

Many Michiganders found Public Act 4 to be a violation of a strong state tradition of "home rule," and so overturned it by referendum in the 2012 election. But that didn't last long: the Republican-dominated state legislature immediately passed Public Act 436, which was almost identical, although it included a provision to pay the emergency managers from state coffers rather than local. Under Michigan law, a bill that includes an appropriation like this cannot be voided through referendum.

Some emergency managers, true, delegated limited responsibilities to the mayor or to members of the city council, but they always retained (and used) their powers to void any decision with which they disagreed. This is the key point that early coverage by flagship newspapers like the New York Times and the Washington Post neglected to mention: From 2011 to 2015, Flint officials had no real control over municipal policy...

THURSDAY UPDATE

The Next Flint
The communities most susceptible to calamitous infrastructure failures are marginalized places inhabited by marginalized people. And many of them are suburbs.

hen Rohan Hepkins, the mayor of Yeadon, Pennsylvania, heard about the water crisis in Flint, Michigan, he sensed a pang he’s known for a while. “I just felt like, here we go again. That’s what happens to the disenfranchised.”

It’s also what could happen to older communities with aging infrastructure and declining tax revenues. No community can avoid the fact that America’s water infrastructure could require an investment of $1 trillion or more over the next 25 years. Some places, however, are more susceptible to crisis than others. An unholy brew of circumstances created the tragedy in Michigan—in which a money-saving decision to switch water supplies corroded the coating in Flint’s aging pipes, contaminating the supply with lead—yet similar circumstances afflict marginalized municipalities populated by marginalized people across the nation. Some of the most vulnerable communities are small post-industrial cities, like Flint. But the next infrastructure crisis is just as likely to occur in an aging, inner-ring, mostly black or Latino suburb.

“The post–World War II suburbs are starting to sag, because they were not meant to last this long,” says Myron Orfield, director of the Institute on Metropolitan Opportunity at the University of Minnesota Law School. “The housing is rotten, the infrastructure is rotten. But it is the nonwhite suburbs that are the poorest places in metro America, with the smallest tax bases. There are thousands of them, and they are all going to have Flint problems all over the country”...

What a mess.

There are roughly 7.3 million lead service lines in the U.S., according to an estimate by the Environmental Protection Agency, down from 10.5 million in 1988. Service lines are the pipes connecting water mains to people's houses. They're mostly found in the Midwest and Northeast.

Despite the life-altering consequences of lead poisoning, there is no national plan to get rid of those pipes. A top reason for continuing to use lead service lines instead of immediately digging them up is that utilities can treat water so it forms a coating on the interior of the pipes -- a corrosion barrier that helps prevent lead particles from dislodging and traveling to your faucet. But if the water chemistry changes, the corrosion controls can fail.

Link.

Documentary filmmaker and Flint MI native Michael Moore is not amused.

MORE...

Amid denials, state workers in Flint got clean water

LANSING -- In January of 2015, when state officials were telling worried Flint residents their water was safe to drink, they also were arranging for coolers of purified water in Flint's State Office Building so employees wouldn't have to drink from the taps, according to state government e-mails released Thursday by the liberal group Progress Michigan.

A Jan. 7, 2015, notice from the state Department of Technology, Management and Budget, which oversees state office buildings, references a notice about a violation of drinking water standards that had recently been sent out by the City of Flint...

State officials could not immediately answer e-mailed questions about the water purchases, including how long the state continued to buy bottled water for state employees in Flint while telling Flint residents the water was safe to drink. An official said the administration was "looking into these issues."

Lonnie Scott, executive director of Progress Michigan, said it appears the state was not as slow as initially thought in responding to the Flint drinking water crisis.

“Sadly, the only response was to protect the Snyder administration from future liability and not to protect the children of Flint,” Scott said. “While residents were being told to relax and not worry about the water, the Snyder administration was taking steps to limit exposure in its own building”...

 Oops.
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More to come...